***TASK*** the task is to summarize an input biomedical literature in six sentences 
    ***INPUT*** the input is a biomedical literature 
    ***OUTPUT*** the output is the summary of an input biomedical literature in six sentences 
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    Input: PURPOSE / OBJECTIVES To evaluate the success of a multifaceted , hospicewide , nurse-focused pain-management intervention for improving patient pain outcomes . DESIGN Comparative , descriptive . SETTING A large , nonprofit hospice that primarily provides home care . SAMPLE Two sample s were included in the study . One sample ( n = 47 ) was from a study completed in 1995 before the intervention , and one ( n = 255 ) was from a study completed in 1997 after the intervention . All patients had been diagnosed with cancer and were alert and able to self-report . METHODS Secondary analysis of data that were collected as part of two quality -of-life studies . The four-part intervention included intensive pain-management education for the nurses , development and implementation of pain-management policies and procedures , changes in pain assessment and management documentation , and development and use of quality assurance monitors by the nursing staff . MAIN RESEARCH VARIABLES Pain at its worst , pain relief , and quality of life . FINDINGS Adjusted mean pain-relief scores were significantly lower in 1995 ( X = 5.8 ) than in 1997 ( X = 8.4 ) . In 1995 , 43 % of patients reported pain relief at a level of 5 or less ( on a 0 - 10 scale ) . This number dropped to 10 % by 1997 . Adjusted mean pain-at-its-worst scores were significantly lower in 1997 ( X = 6.1 ) than in 1995 ( X = 6.7 ) . Pain relief was found to be positively correlated ( r = 0.41 - 0.51 ) with quality of life in both sample s. CONCLUSIONS The hospicewide pain-management intervention was effective . IMPLICATION S FOR NURSING PRACTICE Through careful study and multifaceted nurse-focused interventions , pain outcomes of hospice patients with cancer can be improved We tested whether computer-based decision support ( CBDS ) could enhance the ability of primary care physicians ( PCPs ) to manage chronic pain . Structured summaries were generated for 50 chronic pain patients referred by PCPs to a pain clinic . A pain specialist used a decision support system to determine appropriate pain therapy and sent letters to the referring physicians outlining these recommendations . Separately , five board-certified PCPs used a CBDS system to “ treat ” the 50 cases . A successful outcome was defined as one in which new or adjusted therapies recommended by the software were acceptable to the PCPs ( i.e. , they would have prescribed it to the patient in actual practice ) . Two pain specialists review ed the PCPs ’ outcomes and assigned medical appropriateness scores ( 0 = totally inappropriate to 10 = totally appropriate ) . One year later , the hospital data base provided information on how the actual patients ’ pain was managed and the number of patients re-referred by their PCP to the pain clinic . On the basis of CBDS recommendations , the PCP subjects “ prescribed ” additional pain therapy in 213 of 250 evaluations ( 85 % ) , with a medical appropriateness score of 5.5 ± 0.1 . Only 25 % of these chronic pain patients were subsequently re-referred to the pain clinic within 1 yr . The use of a CBDS system may improve the ability of PCPs to manage chronic pain and may also facilitate screening of consults to optimize specialist utilization OBJECTIVE Efforts to improve  pain assessment and treatment in critically ill patients are poorly studied and represent an opportunity to improve quality of care . We sought to improve  pain assessment and treatment in patients in a surgical intensive care unit at an academic medical center . DESIGN We performed a prospect i ve study of pain assessment and treatment in two surgical intensive care units in 2001 . We measured  pain assessment as the percentage of 4-h intervals where the patient 's pain was measured using a visual analog scale . We measured pain treatment as the percentage of 4-h intervals where the patient 's pain score on the scale was < or =3 . We then implemented four separate " plan-do- study -act " cycles to improve pain assessment and treatment . MAIN OUTCOME MEASURES We evaluated the percentage of 4-h patient-nursing intervals that were scored numerically pre- and post-intervention . We evaluated the percentage of 4-h patient-nursing intervals where the patients had a pain score of < or =3 pre- and post-intervention . In addition , we monitored  naloxone  use as a measure of adverse events related to pain treatment . RESULTS Our baseline assessment of pain was 42 % and the baseline treatment was 59 % . After 5 weeks , pain assessment improved to 71 % and pain management improved to 97 % . CONCLUSION Our interventions were associated with significant improvements in pain assessment and treatment without an increase in adverse events related to pain therapy . Our interventions were relatively simple and may be implemented broadly . Our interventions provide insights into the application of complexity theory in improvement efforts The purpose of this study was to vali date the changes in acute pain measurement scales that are most strongly associated with a patient-determined indicator of clinical importance . Measures of pain intensity and pain relief are commonly used outcomes in therapeutic clinical trials . Recent studies of the properties of acute pain measures have provided data defining the cut-off points that are best associated with clinical ly important differences . Validation of these findings in another clinical trial data set is important . Data were obtained from the titration phase of a recently conducted r and omized controlled clinical trial of oral transmucosal fentanyl citrate ( OTFC ) , which compared OTFC to immediate release morphine sulfate ( MSIR ) for the treatment of cancer-related acute breakthrough pain .  Changes in pain intensity and pain relief were recorded every 15 minutes for 60 minutes and global medication performance recorded at the end of each study pain episode . At any titration step , if the patient felt that the first dose of the study medication did not provide adequate relief within 30 minutes , an additional rescue medication could be taken . To find the level of each pain scale best associated with this measure of the adequacy of pain relief , the calculated sensitivity , specificity , and accuracy for different cut-off points of the measured pain scales were compared to whether or not the patient needed rescue medication . The overall ability of the pain measures to discriminate episodes for which a rescue was not needed was calculated using area under the receiver operating characteristics ( ROC ) curves . Data were analyzed from 134 OTFC-naive patients who collected data on 1307 episodes of breakthrough pain . Using the criteria of a balanced sensitivity and specificity , the best cut-off points were determined to be : 33 % for the percent pain intensity difference ; > or = 2 for the raw pain intensity difference on a 0 - 10 numeric rating scale ; > or = 2 ( i.e. , moderate or better ) for pain relief ; > or = 33 % for the percent maximum total pain relief ; and > or = 2 ( good or better ) for global medication performance . ROC area under the curve ranged from 0.839 to 0.862 for each of the pain measures listed above , calculated at 60 minutes . These data indicate that the pain scale cut-off points that are best associated with a patient-derived measure of a clinical ly important difference closely approximate those found in an earlier study . ROC analysis provided evidence that the overall pain measures were strongly associated with not requiring an " additional dose of rescue medication . " Thus , the cut-off points determined for these pain scales provide a good surrogate measure of a patient-determined clinical ly important response . This provides support for the usefulness of these values in future clinical trials of pain therapy & NA ; Reliable and valid measures of pain are essential for conducting clinical trials of pain treatments . Perhaps the most important aspect of a pain measure 's validity is its sensitivity , or ability to detect changes in pain over time and due to treatment . Several factors may affect a measure 's sensitivity , including the complexity of the rating task for the measure , the number of pain intensity levels assessed by the measure , the dimension of pain assessed ( e.g. pain intensity vs. pain relief ) , and the number of individual ratings ( e.g. single rating vs. composite score ) used to create the measure . The purpose of this study was to compare the relative sensitivity of three measures of outcome and a composite made up of all three measures for detecting analgesic effects in two sample s of persons participating in a r and omized controlled trial . One hundred and twenty‐three patients who had undergone knee surgery and 124 women who had undergone a laparotomy were given one of three medications in the day after their surgery : morphine , ketorolac , or placebo . Two measures of pain intensity ( a visual analog scale ( VAS ) and a 4‐point verbal rating scale ( VRS ) ) were administered at baseline , and these measures plus a 5‐point VRS of pain relief were administered at 16 additional time points up to 24 h following surgery . As predicted , we found variability in the sensitivity of the outcome measures used in these studies , with the 4‐point VRS showing less sensitivity than the VAS or relief ratings . However , contrary to our prediction , a composite measure of outcome made up of all three measures was not consistently superior to the individual measures for detecting treatment effects . Finally , we found that pain relief ratings were related to , but also distinct from , change in pain intensity as measured by changes in pain intensity ratings from baseline to each postmedication assessment point . These findings have important implication s for the assessment of pain in clinical trials BACKGROUND The Joint Commission on Accreditation of Health Care Organizations declared pain level to be the " fifth vital sign . " This has led to increased efforts to reduce patients ' pain scores . Current postoperative analgesic modalities may not be entirely safe . We prospect ively studied pain and sedation scores to determine whether postoperative patients were reaching sedation levels similar to patients undergoing " conscious sedation " ( eg , colonoscopy cases ) . " Conscious sedation " patients have been shown to achieve states of sedation , which at time result in oxygen desaturation . METHODS Fifty-three patients within three groups were compared in an observational study . Group 1 included  " conscious sedation " patients undergoing colonoscopy .  Group 2 included  postoperative patients using patient-controlled analgesia ( PCA ) .  Group 3 included  postoperative patients under nurse-controlled analgesia ( NCA ) .  Levels of sedation were monitored using the 6-point Ramsay sedation scale . Pain and oxygen saturation were monitored using an 11-point verbal scale and finger pulse oximetry , respectively . Patients were monitored for up to 12 hours in the postoperative period or for the length of their colonoscopy procedure . RESULTS Patients in groups 1 and 2 reached similar sedation levels . CONCLUSIONS Patients may reach dangerous levels of sedation during the first 24 hours postoperatively . Patients using PCA devices warrant close observation during this time period Pain complicates the recovery process after ambulatory surgery . We surveyed 175 ambulatory surgery patients to determine  pain severity , analgesic use  , relationship of pain to duration of recovery , and the relative importance of various factors to predicting these outcomes . Multivariate regression analysis was used to determine unique contributions of predictor variables to outcome . Surgical procedures included knee arthroscopy ( n = 50 ) , hernia surgery ( n = 25 ) , pelvic laparoscopy ( n = 25 ) , transvaginal uterine surgery ( n = 25 ) , surgery for breast disease ( n = 25 ) , and plastic surgery ( n = 25 ) . Maximum pain ( on a scale of 0–10 ) varied from 2.3 ± 0.5 to 5.1 ± 0.5 ( mean ± se ) , depending on surgical procedure ; 24 % of patients had pain scores of ≥7 , and 24 % were delayed in Phase 1 recovery by pain . Pain scores were lower if local anesthetic or ketorolac was administered intraoperatively ( 22 % and 26 % respectively ) . Fentanyl dose during recovery correlated with maximum pain scores ; fentanyl dose was 42 % less if ketorolac was administered intraoperatively . In females , the recovery fentanyl dose increased in proportion to the intraoperative fentanyl dose . The maximum pain score was predictive of total recovery time ( 135 , 172 , and 212 min of recovery for maximum pain scores of 0–3 , 4–6 , and 7–10 , respectively;P < 0.001 ) . We conclude that improvements in pain therapy are warranted to improve patient comfort and to expedite recovery OBJECTIVES To describe the impact of musculoskeletal pain ( MP ) ; to compare management of MP by the population and by primary care physicians ; and to identify misconceptions about treatment . METHODS 5803 people with MP and 1483 primary care physicians , r and omly selected , in eight European countries were interviewed by telephone . A structured question naire was used to ask about usual management of MP and perceived benefits and risks of treatment .  Current health status ( SF-12 ) was also assessed . RESULTS From primary care physicians ' perceptions , MP appears to be well managed . All presenting patients are offered some form of treatment , 90 % or more doctors are trying to improve patients ' quality of life , and most are aware and concerned about the risks of treatment with NSAIDs . From a population perspective , up to 27 % of people with pain do not seek medical help and of those who do , several wait months/years before seeing a doctor . 55 % or fewer patients who have seen a doctor are currently receiving prescription treatment for their pain . Communication between doctors and patients is poor ; few patients are given information about their condition ; and many have misconceptions about treatment . CONCLUSIONS Management of MP is similar across eight European countries , but there is discordance between physician and patient perspectives of care . Some people with pain have never sought medical help despite being in constant/daily pain . Those who do seek help receive little written information or explanation and many have misperceptions about the benefits and risks of treatment that limit their ability to actively participate in decisions about their care CON 
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RESULTS The recommendations specify that all care setting s formulate structured , multilevel systems approaches ( sensitive to the type of pain , population served , and setting of care ) that ensure prompt recognition and treatment of pain , involvement of patients and families in the pain management plan , improved treatment patterns , regular re assessment and adjustment of the pain management plan as needed , and measurement of processes and outcomes of pain management .