APPENDIX A. Search Strategy 

Database: Ovid MEDLINE(R) <1996 to April Week 1 2007> 

Search Strategy: 

-------------------------------------------------------------------------------- 

1 Analgesia/ or Analgesics, Opioid/ or Pain/ or Anti-Inflammatory Agents, NonSteroidal/ or acute pain.mp. or Pain Measurement/ or Analgesics/ (89900) 

2 Meta-Analysis/ or "Review Literature"/ or systematic review.mp. (15321) 

3 1 and 2 (661) 

4 limit 3 to english language (596) 

5 from 4 keep 1-596 (596) 

Targeted search strategy for primary studies on KQ1: 

Database: Ovid MEDLINE(R) <1950 to July Week 2 2007> 

Search Strategy: 

-------------------------------------------------------------------------------- 

1 exp Pain/ (212174) 

2 exp Pain Measurement/ (31393) 

3 ((assess$ or measur$) adj3 pain$).mp. [mp=title, original title, abstract, name of 

substance word, subject heading word] (37632) 

4 acute pain$.mp. (2813) 

5 1 or 2 or 3 or 4 (226036) 

6 exp Hospitalization/ (104116) 

7 exp Inpatients/ (6381) 

8 exp patient admission/ (12978) 

9 exp Emergency Medical Services/ (60608) 

10 6 or 7 or 8 or 9 (163418) 

11 5 and 10 (5687) 

12 exp Time/ (845509) 

13 11 and 12 (778) 

14 limit 13 to (humans and english language) (657) 

15 from 14 keep 1-657 (657) 

Targeted search strategy for primary studies on the use of PCA in non-surgical settings, 

for KQ2: 

Database: Ovid MEDLINE(R) <1950 to July Week 3 2007> 

Search Strategy: 

-------------------------------------------------------------------------------- 

1 Analgesia, Patient-Controlled/ (2508) 

2 limit 1 to english language (2205) 

3 limit 2 to meta analysis (14) 

4 exp Surgical Procedures, Operative/ (1661433) 

5 su.fs. (1152982) 
6 exp Postoperative Complications/ (307984) 

7 4 or 5 or 6 (2196325) 

8 2 not 7 (612) 

9 from 8 keep 1-612 (612) 

Initial exploratory search strategies for systematic reviews, conducted in January 2007 

(postoperative pain was subsequently excluded from the scope): 

Acute Pain Management: Postoperative and Inpatient Settings 

January 23, 2007 

Search strategy 1: PubMed Clinical Queries - Limits; human, English

(pain [mh] AND (drug therapy [sh] OR therapy [sh] OR psychology [sh] OR surgery 

[sh])) AND systematic[sb]: 

((pain,postoperative [mh] OR acute disease [mh]) AND pain measurement [mh]) AND 

systematic[sb])) 

Search strategy 2: PubMed 

pain,postoperative [mh] AND evidence-based medicine [mh] AND acute [tw] = 17 

Search strategy 3: Cochrane library 

Pain management 

Pain (and) evidence (and) assessment 

Pain in Record Title and management in Record Title and evidence in Record Title in 

Database of Abstracts of Reviews of Effects 

(1-23-07) 

 Search strategy 4: PubMed : Acute pain in patients with cognitive impairment or acute 

psychiatric illness 

pain [mh] AND (drug therapy [sh] OR therapy [sh] OR psychology [sh]) AND mental 

disorders [mh] 

Search Strategy 5 - PM Clinical Queries – 

pain [mh] AND (drug therapy [sh] OR therapy [sh] OR psychology [sh]) AND mental 

disorders [mh] 

Search strategy 6: PM Clin Quer 

(Pain [mh] AND (delirium [tw] OR dementia [tw])) AND systematic[sb] 
(1-29-07 – Pubmed) 

pain, postoperative [mh] AND (timing [tw] OR assessment [tw]) AND evidence based 

medicine [mh] = 19 

pain measurement [mh] AND evidence based medicine [mh] = 104 

March 20, 2007 

Ovid search 1 

1.pain, postoperative.mp. or Pain, Postoperative/ 

OR acute disease.mp. or Acute Disease/ 

AND 

patient satisfaction.mp. or Patient Satisfaction/ = 298 

Ovid search 2 

pain measurement.mp. [mp=title, original title, abstract, name of substance word, subject 

heading word] 

OR 

acute disease.mp. [mp=title, original title, abstract, name of substance word, subject 

heading word] 

AND 

"Outcome Assessment (Health Care)"/ 

Ovid search 3 =6 

pain, postoperative.mp. or Pain, Postoperative/ 

AND 

patient satisfaction.mp. or Patient Satisfaction/ 

AND 

questionnaires.mp. or Questionnaires/
APPENDIX A, continued. Table of systematic reviews and studies cited, by key question 

Title Conditions Special populations KQ1 KQ

Acute Pain Management: Scientific Evidence.(1) 

Post-operative pain and acute pain in spinal cord injury, burns, cancer, acute zoster, neurological diseases, haematological disorders (e.g. sickle cell disease) HIV/AIDS, renal and biliary colic, musculoskeletal and orofacial pain and headache, phantom limb pain 

Elderly, opioid-tolerant patients, patients with obstructive sleep apnea, renal or hepatic impairment or a substance abuse disorder

(2, 3) (4-1

Tools for assessment of pain in nonverbal older adults with dementia: a state-of-the-science review (29) 

Types of pain not specified. The assessment scales measured pain by observation of behavioral indicators. 

Nonverbal elderly patients with cognitive impairment 

-- -- 

Observation scales for pain assessment in older adults with cognitive impairments or communication difficulties (40) 

Types of pain not specified. The assessment scales measured pain by observation of behavioral indicators. 

Elderly patients with cognitive impairments, communication difficulties, or both. 

-- -- 

Pain in elderly people with severe dementia: a systematic review of behavioural pain assessment tools (46) 

Types of pain not specified. The assessment scales measured pain by patient self-report, or behavioral measures. 

Elderly patients with cognitive impairment 

-- -- 

Institutional Approaches to Pain Assessment and Management (2003).(53) 

Postoperative pain, nonsurgical pain, cancer, HIV disease, sickle cell crisis 

-- -- (54-

Do opiates affect the clinical evaluation of patients with acute 

Acute abdomen -- -- (64-
abdominal pain? (63) 

Nonsteroidal anti-inflammatory drugs (NSAIDS) versus opioids for acute renal colic (73) 

Acute renal colic pain -- -- (74-

Comparing analgesic efficacy of non-steroidal anti-inflammatory drugs given by different routes in acute and chronic pain: a qualitative systematic review (93) 

Included 3 trials in renal colic 

-- -- (94-

Hydromorphone for acute and chronic pain (97) 

Included one trial in patients with renal colic, and one trial in patients with biliary stone pain. 

-- -- (98, 

Pain management in hospitalized cancer patients: a systematic review (100) 

Cancer -- -- (10

105

Evidence for the optimal management of acute and chronic phantom pain: a systematic review. (5) 

Phantom limb pain after amputation 

-- -- (11, 

18

106114
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and bupivacaine. Annals of the Royal College of Surgeons of England 

1994;76(5):324-6. 

109. Nikolajsen L, Ilkjaer S, Christensen JH, Kroner K, Jensen TS. Randomised trial 

of epidural bupivacaine and morphine in prevention of stump and phantom pain in 

lower-limb amputation. Lancet 1997;350(9088):1353-7. 

110. Conine TA, Hershler C, Alexander ST, Crisp R. The efficacy of Farabloc in the 

treatment of phantom limb pain. Can J Rehabil 1993;6:155-61. 

111. Katz J, Melzack R. Auricular transcutaneous electrical nerve stimulation (TENS) 

reduces phantom limb pain. Journal of Pain & Symptom Management 

1991;6(2):73-83. 

112. Elizaga AM, Smith DG, Sharar SR, Edwards WT, Hansen ST, Jr. Continuous 

regional analgesia by intraneural block: effect on postoperative opioid 
requirements and phantom limb pain following amputation. Journal of 

Rehabilitation Research & Development 1994;31(3):179-87. 

113. Fisher A, Meller Y. Continuous postoperative regional analgesia by nerve sheath 

block for amputation surgery--a pilot study. Anesthesia & Analgesia 

1991;72(3):300-3. 

114. Finsen V, Persen L, Lovlien M, Veslegaard EK, Simensen M, Gasvann AK, et al. 

Transcutaneous electrical nerve stimulation after major amputation. Journal of 

Bone & Joint Surgery - British Volume 1988;70(1):109-12. 
APPENDIX B. Inclusion/exclusion criteria 

Code Include / Reason 

Exclude

Published primary research, systematic review, or meta-analysis of studies that I1 Include 

a. Were conducted in inpatients with acute pain (including patients with 

impaired self-report; patients with prexisting opiate therapy; and 

patients with dependencies on tobacco, alcohol, opioids, or other 

substances) 

b. Report data on any of the following 

i. Association between timing and frequency of pain assessment, 

severity of pain, and choice of treatment (e.g. regional blocks, 

medications, or other therapies) 

ii. Method of pain assessment (e.g. 11-point pain scale, visual 

analog scale, verbal descriptor scale 

iii. Timing and route of administration of pain interventions (e.g. 

oral intermittent pharmacotherapy, intravenous therapy, 

psychological interventions, positioning, neural blockade, and 

patient-controlled analgesia); timeliness of enactment of 

treatment plans, changes in treatment plans 

iv. Effect of coordination of care with the patient’s primary care 

physician or with a pain consultation service on choice of 

treatment, clinical outcomes, and safety 

v. Patient outcomes, including degree of pain relief, pain intensity, 

emotional well-being, patient satisfaction, physical function, and 

fitness for rehabilitation of the underlying condition 

vi. Safety outcomes; severity and frequency of side effects 

(including somnolence, respiratory depression, confusion, 

constipation, ileus, vomiting, non-allergic itching, 

weakness/numbness, and use of naloxone) 

vii. Length of stay 

viii. Follow-up of pain 

Unpublished research meeting I1 criteria I3 Include 

Non-systematic review or background article meeting I1 criteria I4 Include 

Other (specify) I5 Include 

X1 Exclude Study outcome does not meet I1 criteria 

Study population does not meet criteria (e.g. outpatients; inpatients 

hospitalized 10 days or longer) 

X2 Exclude 

Type of pain not within scope of review (e.g. post-operative pain, sickle cell 

disease, cancer pain, chronic pain in patients hospitalized 10 days or longer for 

whom pain is chronic or refractory) 

X3 Exclude 

X4 Exclude Pain intervention studied is not routinely available in the VA health system 

X5 Exclude Non-English language, no abstract 

X6 Exclude Non-human, animal 

X7 Exclude Other (specify, e.g. off-topic) 

X8 Exclude Wrong study design; no data 
APPENDIX C. USPSTF Quality Rating Criteria 

Diagnostic Accuracy Studies 

 

Criteria 

• Screening test relevant, available for primary care, adequately described

• Study uses a credible reference standard, performed regardless of test results

• Reference standard interpreted independently of screening test

• Handles indeterminate results in a reasonable manner

• Spectrum of patients included in study

• Sample size

• Administration of reliable screening test

Definition of ratings based on above criteria 

Good: Evaluates relevant available screening test; uses a credible reference standard; interprets 

reference standard independently of screening test; reliability of test assessed; has few or 

handles indeterminate results in a reasonable manner; includes large number (more than 100) 

broad-spectrum patients with and without disease. 

Fair: Evaluates relevant available screening test; uses reasonable although not best standard; 

interprets reference standard independent of screening test; moderate sample size (50 to 100 

subjects) and a “medium” spectrum of patients. 

Poor: Has important limitations such as: uses inappropriate reference standard; screening test 

improperly administered; biased ascertainment of reference standard; very small sample size 

of very narrow selected spectrum of patients. 

Randomized Controlled Trials (RCTs) and Cohort Studies 

Criteria 

• Initial assembly of comparable groups: RCTs—adequate randomization, including 

concealment and whether potential confounders were distributed equally among groups; cohort 

studies—consideration of potential confounders with either restriction or measurement for 

adjustment in the analysis; consideration of inception cohorts 

• Maintenance of comparable groups (includes attrition, cross-overs, adherence, contamination) 

• Important differential loss to follow-up or overall high loss to follow-up 

• Measurements: equal, reliable, and valid (includes masking of outcome assessment) 

• Clear definition of interventions 

• Important outcomes considered 

• Analysis: adjustment for potential confounders for cohort studies, or intention-to-treat analysis 

for RCTs (i.e. analysis in which all participants in a trial are analyzed according to the 

intervention to which they were allocated, regardless of whether or not they completed the 

intervention) 
Definition of ratings based on above criteria 

Good: Meets all criteria: Comparable groups are assembled initially and maintained throughout the 

study (follow-up at least 80 percent); reliable and valid measurement instruments are used 

and applied equally to the groups; interventions are spelled out clearly; important outcomes 

are considered; and appropriate attention to confounders in analysis. 

Fair: Studies will be graded “fair” if any or all of the following problems occur, without the 

important limitations noted in the “poor” category below: Generally comparable groups are 

assembled initially but some question remains whether some (although not major) differences 

occurred in follow-up; measurement instruments are acceptable (although not the best) and 

generally applied equally; some but not all important outcomes are considered; and some but 

not all potential confounders are accounted for. 

Poor: Studies will be graded “poor” if any of the following major limitations exists: Groups 

assembled initially are not close to being comparable or maintained throughout the study; 

unreliable or invalid measurement instruments are used or not applied at all equally among 

groups (including not masking outcome assessment); and key confounders are given little or 

no attention. 

Case Control Studies 

Criteria 

• Accurate ascertainment of cases 

• Nonbiased selection of cases/controls with exclusion criteria applied equally to both 

• Response rate 

• Diagnostic testing procedures applied equally to each group 

• Measurement of exposure accurate and applied equally to each group 

• Appropriate attention to potential confounding variable 

Definition of ratings based on above criteria 

Good: Appropriate ascertainment of cases and nonbiased selection of case and control participants; 

exclusion criteria applied equally to cases and controls; response rate equal to or greater than 

80 percent; diagnostic procedures and measurements accurate and applied equally to cases 

and controls; and appropriate attention to confounding variables. 

Fair: Recent, relevant, without major apparent selection or diagnostic work-up bias but with 

response rate less than 80 percent or attention to some but not all important confounding 

variables. 

Poor: Major selection or diagnostic work-up biases, response rates less than 50 percent, or 

inattention to confounding variables
APPENDIX D. Reviewer Comments and Responses - VA ESP Acute Pain Management in Inpatients

Reviewer Comment Response Karl Lorenz

Overall, the review provides a helpful summary of clinical questions relevant to expanding pain services, developing standards, and prioritizing a research agenda to improve inpatient pain management in medical settings for veterans. They review found little direct evidence to guide acute pain management in medical inpatients, excluding patients with cancer, those in late life, and the surgical settings. 

Noted 

Roger Chou

I think the report does a good job of summarizing the (lack of) evidence for most of the pain management practices in the inpatient setting.

Noted 

Bob Kerns I am reading with considerable interest this review.

One question is puzzling me: I had thought that the review would also include management of pain in surgical settings (note the title of the abstract). Is your intention to provide a separate review with this focus, or did you decide to limit your attention to non surgical, acute medical settings? Or did we simply miscomunicate our intentions?

Regarding the scope, note that before we began the the ESP committee agreed to a statement that says with post operative pain, sickle cell disease, and canand patients who have been hospitalized 10 days or are excluded."

Roger Chou

1) Exclusion of sickle cell patients: I don't remember the justification for excluding sickle cell patients, but it might seem funny to readers/users of the report because sickle cell is probably the population with the most data on pain management in the inpatient setting. I think the reasoning for exclusion should at least be described. Also, it seems a bit inconsistent that evidence on outpatients and cancer pain patients and post op are mentioned in relevant spots but sickle cell evidence is generally not described and is arguably more (or just as) relevant.

See above. 

VA-ESP 03/17/08 1 of 4
APPENDIX D. Reviewer Comments and Responses - VA ESP Acute Pain Management in Inpatients

Reviewer Comment Response Karl Lorenz

1. The evidence tables cite about 25 retained studies. 390 studies were reviewed in detail. An accounting of the reasons for exclusion is needed, as well as a summary description of retained studies – overlap and relevance of titles for each question, and a description of the study designs used to answer each question.

This infomation is available upon request. 

Karl Lorenz

2. A very brief quantitative summary of the studies included at the beginning of each section would be helpful.

Agree. 

Karl Lorenz

3. It is somewhat confusing to have the systematic reviews cited in the text for evidence, but for them to be missing in the tables (which may be used by some readers as the primary source of information). I suggest you include a ‘systematic review table’ in which you highlight the evidence related to each review (e.g., systematic reviews cited in text for pca as refs 57-66 and so forth) – relevant to each question and note that the current tables are ‘other studies’ not covered in the reviews (if that’s the case).

Agree 

VA-ESP 03/17/08 2 of 4
APPENDIX D. Reviewer Comments and Responses - VA ESP Acute Pain Management in Inpatients

Reviewer Comment Response Jack Rosenberg

What is obvious is that the search strategy for this may be flawed. Namely, specific disease entities that make up acute non surgical pain were not searched. I also did not see the years of publications that were covered. Much of the literature may be old. Just looking at kidney stone pain for 30 minutes , I pulled these four articles that describe treatment of pain for this entity that are not covered in this review. I did not have the time to go and pull the supporting references.So for a brief synopsis of my opinion, the search for articles should be repeated looking at the questions in reference to particular entities that make up acute pain. for example acute fractures of hip, pelvis, spine)), abdominal, including pancreatic and others. I am also not sure that excluding exacerbations of chronic pain (also called acute on chronic pain) serves us well. There is not much literature on this subject, but these suggestions should help increase the information for analysis.

Our initial searches used broader terms than the spedisease entities; in a supplemental search, using the names did not identify additional relevant literature. conducted a series of supplemental searches relaxincriteria used in the original searches. These identifiepotentially relevant abstracts. One of these was a randomized trial of morphine for acute abdominal paemergency room which supported the findings of a systematic review (by Ranji et al) of 12 trials but was recent to be included in that review. The others conclinical settings and conditions that were excluded frreview.

Roger Chou

2) The quality of included studies is summarized in the appendix tables and in the summary table but is not always clear when reading the text. I don't think you need to spend a lot of time describing quality of non RCTs but for RCTS and when describing results of SR's it is probably important to make some mention about quality of the RCTs or studies included in the SR's.

Agree 

VA-ESP 03/17/08 3 of 4
APPENDIX D. Reviewer Comments and Responses - VA ESP Acute Pain Management in Inpatients

Reviewer Comment Response Roger Chou

3) Regarding KQ #2, some guidelines recommend against use of IM opioid b/c they are equally well absorbed SQ (based on PK data) and this probably should be mentioned at least as background info. Also, there are some old RCTs in cancer pain setttings showing no difference between rectal and oral morphine (Beaver WT 1967 [2 studies]), or IM vs. oral opioids (Babul N 1998 and De Conno F 1995) if you want to describe results from other populations.

This pertains to question 2d. In the section on renal said: "Most evidence about treating renal colic is old addresses whether to use IM or IV analgesics. The findings, discussed in more detail below, are (1) NSAprovide effective analgesia for acute renal colic, and more quickly through the IV route than by IM or PR 2Opioids provide analgesia that is equivalent to NSAIresult in a higher incidence of vomiting and other adevents, particularly pethidine 3) Hydromorphone prosuperior pain relief and led to fewer hospital admisscompared with meperidine in one study." We revised make the point suggested by the reviewer.

Roger Chou

4) The section on PCA doesn't talk about use of basal infusion + prn versus prn only. My understanding is that some studies suggest that the basal infusion increases opioid use but doesn't improve pain, but I don't have any studies to cite for that. I do think it's a pretty common question on the inpatient setting though, with some people being taught to use basal infusions depending on how much opioid the patient required the previous day etc. Might be worth mentioning as an issue and the evidence (or lack thereof).

This is an important issue clinically, but it is beyond of resolution of the literature about nonsurgical pain That is, we didn't find any literature about it in the tapopulation.

Karl Lorenz

Reviewer provided detailed advice for restructuring the future research section (see attached review)

Agree with reorganizing this section using the reviewproposed outline.

VA-ESP 03/17/08 4 of 4
APPENDIX E. Evidence Summary Tables 

Summary Table 1. Studies on methods of pain assessment (KQ1) 

Study 

Design, 

setting 

Author, 

Year 

Clinical condition/ 

baseline pain 

Intervention/exposure of 

interest 

Outcomes 

measured Sample size 

Prospective cohort 

267 39.5% acute pain, 

40.3% chronic pain. 20.9% reported no pain on admission. Mean for pain intensity ranged from 5.09-5.75. 

Patients rated the intensity of pain using each of the 3 scales once over the next 24 hours were also asked which of the scales was easiest to use, whether the scale was helpful or needed further explanation, and employment and education data. 

Use of 3 self-rated pain scales; questionnaire also collected demographic information and perceptions about scales. 

Patients mofaces scale number sca(16.1%). Novariables weReliability co(Chronbach(85.8%) patrating scale pain to the n

Carey, 19971

Single-site prospective study, convenience sample in Innsbruck, Austria 

10 EMS technicians, 10 EMS drivers, 2 ER physicians; 15 trauma patients and 36 nontrauma patients (mostly cardiovascular disease). 

15 trauma patients: 7 fractures or lacerations, 5 blunt injuries, 3 penetrating wounds. 

Pain assessment was performed at the beginning of emergency care before analgesics, during transport, and upon arrival at the hospital immediately prior to hospitalization. 

Severity of pain assessed by patient; EMS physician; EMS technician; EMS driver; at 3 time points (on the scene, during transport, and on arrival at hospital) 

The EMS ph47% of the tunderestimaEMS driver the time. Th68%) amonand lowest mild pain. The pain intwere highly p=0.0001). 

Luger, 20032

Retrospective cohort study at a suburban universitybased ED 

521 before the mandatory pain scale; 479 after introducing the pain scale to the ED, 

Renal colic, extremity trauma, headache, opthalmologic trauma, or soft tissue injury. Pain varied from 0-10. 8% of patients who reported 0 received analgesia, compared with 74% who reported 9, and 69% who reported 10 as baseline pain. 

The standard triage form was revised to include a pain scale in the vital signs section, and the pain assessment was made at triage at the same time as presentation vital signs were assessed. ED staff and patients were not made aware of the study or alerted to the intervention. 

1) The proportion of patients who received oral or parenteral analgesia for their pain while in the ED; 2) the time to analgesia administration 

The proportanalgesia ascale increa(p<0.001). analgesia abefore the inafter (mean -7 to 84) bustatistically diagnostic uevaluation wanalgesia. received anwho underwpatients with underwent Cwhereas 62undergo CT 

Nelson, 20043

VA ESP - Management of Acute Pain in Inpatients 
APPENDIX E. Evidence Summary Tables 

Summary Table 1. Studies on methods of pain assessment (KQ1), continued 

Study 

Design, 

setting 

Author, 

Year 

Sample 

size 

Clinical condition/ 

baseline pain 

Intervention/exposure 

of interest Outcomes measured 

Morrison, 2006

Controlled clinical trial in an 1171-bed hospital in Mt. Sinai Hospital, New York. 

3964 

adults 

9 medical/surgical units were selected for inclusion based on similar baseline patient demographics and pain scores (3 general medicine, 2 general surgery, 2 specialty surgery, 1 oncology, and 1 mixed oncology/general medicine). 32-38% surgical pts10-16% cancer pts1.5 - 4.8% AIDS pts56% had moderate to complete relief from pain medication29-32% had moderate to severe pain at study enrollment 

Education in pain management (months 0-4) was followed by a series of additive 6 to 7-month intervention periods: 1) patient education and nursing pain assessment of current and worst pain, pain relief, and pain acceptability; 2) audit and feedback to nursing staff of patients' pain intensity and staff compliance; and 3) a computerized clinical decision support system (CDSS) to guide analgesic prescribing. 

Patients were interviewed within 48 hrs of admission and then once daily. Patients were asked to rate current pain, worst pain over 24 hrs, their pain relief with analgesics, and whether their pain was acceptable to them. Pain and pain relief were rated on 4-pt scales. Outcomes included measures of pain assessment, pain severity, and analgesic prescribing. % of patients who had a daily pain assessment for each shift; % of pts wioth moderate to severe pain 72-96 hrs later, mean pain scores for the first 72 hrs or on postop days 1-3 

Pain documenusing an enhainstrument comfeedback or a system. The eassociated witprescribing.Paenhanced pain likely to have ton units in whused (p<0.001results was asincreases in pcompared with feedback (p<0associated witassessment o

that lacked au(p<0.001).Oveat least 1 pain from 32.1% wassessment to pain scale was to more than 8audit and feed

4

VA ESP - Management of Acute Pain in Inpatients 
APPENDIX E. Evidence Summary Tables 

VA ESP - Management of Acute Pain in Inpatients 

Summary Table 2. Studies on the timing and frequency of pain assessment, and timing of treatment (KQ1) 

Author, 

Year 

Study Design, 

setting 

Sample 

size 

Clinical condition/ 

baseline pain 

Intervention/ 

exposure of 

interest 

Outcomes 

measured R

Arendts, 2006 5

Retrospective cohort study in an Australian ED 

857 Thoracic, including 

cardiac 12.9%, abdominal 30.6%, urological 11.4%, gynecological 4%, trauma 31%, neurological 35%, and misc. 6.6%. 15% were admitted to critical care, 49% admitted to general ward, and 19% admitted to ED observation 

Morphine was the drug used in 94% of cases. 

Time from arrival to first dose of opiate. Patients were grouped in 2: time <60 minutes, and time >=60 minutes. 

Median time to first doreceived no alternative Patients with 60+ minube female, older, of lowjunior medical staff, surelated illness, and admdischarged. These premultivariate analysis. 

Grant, 2006 6

Retrospective review of patient records 

473 0r 473 pain patients, 213 

(45%) had severe pain and 105 (22%) had moderate pain. By type of pain:Chest pain: 14-17%Abdominal pain: 19-21%Headache/neuropathic: 8-11%Muscular: 29-32%Skeletal: 11-15%Ears, nose throat: 2-3%NOS 6-12% 

Any form of analgesia 

Time intervals between patient arrival, assessment, and delivery of analgesia. 

For patients with modemean time interval (miassessment: 142 v 42Aanalg: 168 v 58Arrvial 72Delay btw prescriptianalgesia: 68 v 14.% oanalgesia within time fguidelines: 24% in sevpain. 32% of patients analgesia requirement

Hwang, 2006 7

Retrospective review of medical records from a prospective cohort study 

158 Patients reporting 

complaint of pain: 81% 

Transfer administrative data (ADT) on time of registration and discharge was used to determine ED crowding risk factors: ED census and mean ED length of stay (LOS) during the hour the index hip fracture patient arrived. 

4 quality measures:1) time to pain assessment by a physician;2) documentation of administration of pain medication3) type of analgesic (opioid v nonopioid (NSAID, acetaminophen) if given;4) time to pain treatment 

Minutes to first docummean (range): 40 (0-60documented pain treattreatment, minutes: 12analgesia for pain (57% nonopioids).32.8% of pprescribed received mcensus levels greater tsignificantly associated documentation of pain times to pain assessmthat adjusted for age, gdementia, and mean E
APPENDIX E. Evidence Summary Tables 

Summary Table 2. Studies on the timing and frequency of pain assessment, and timing of treatment (KQ1), continue

Intervention/ 

exposure of 

interest 

Author, 

Year 

Study Design, 

setting 

Sample 

size 

Clinical condition/ 

baseline pain 

Outcomes 

measured Re

Ranji, 2006 

Systematic Review of RCTs of opiate analgesia v placebo in acute abdomen 

9 

studies 

in 1062 

adults, 

and 3 

studies 

in 291 

children. 

3 studies enrolled only patients with right lower quadrant pain; all others enrolled patients with undifferentiated acute abdominal pain. 

use of opiate analgesia in acute abdomen 

Effect of opiates on patient history (potential to minimize previously concerning symptoms v. increasing its accuracy by calming the patient); on the physical examination; and on potential management errors 

11 comparisons from 9 strend toward changes in with opiate administration1.51 (95%CI 0.85 - 2.69)heterogeneity among the comparisons, pain relief group did not significantlStudies did not generally potentially beneficial chalocalization of tenderneschanges such as changestudies, loss of periotneaoccurred in 5.6% to 18.7compared with 2.6% to 7group. Diagnostic accuraadult studies indicated no rate of incorrect manageopiates vs. placebo. Anathese studies, and no sigfound. The frequency of surgeries was similar betgroups (7.6% v 7.9%). Mnon-significant trend towsurgeries among patients 

8Shabbir, 2004 

Prospective study in a direct access A&E department where patients were immediately assessed by the surgical on-call service. 

100 Acute abdominal pain. 

Clinical diagnoses included non-specific abdominal pain, PID, peptic ulcer disease, pancreatitis, appendicitis, renal, cholecystitis. 

Most common drugs used:diclofenac 37%pethidine 26%Most common routes used:80% intramuscular route0% received intravenous analgesia. 

Waiting time for analgesia and its relationship to subjective visual analogue pain scores and clinical diagnoses 

Mean waiting time for an(range 2 min to 14 hr).Felonger mean wait time thmin, p=0.09). Patients areceived analgesia quickduring the day time (measatisfied with the adequagiven; 23% thought the psufficient.Neither clinical influenced the timing of a

9

VA ESP - Management of Acute Pain in Inpatients 
APPENDIX E. Evidence Summary Tables 

Summary Table 2. Studies on the timing and frequency of pain assessment, and timing of treatment (KQ1), continue

Clinical 

condition/ 

baseline 

pain 

Author, 

Year 

Study Design, 

setting 

Intervention/ 

exposure of interest Sample size Outcomes measured R

Vila, 2005 Retrospective 

chart review, single hospital: H.Lee Moffitt Cancer Center and Research Institute 

Pre-intervention: 

79 opioid ADRs 

for 117,672 

inpatient hospital 

days, Postintervention: 67 

opioid ADRs for 

65,388 inpatient 

hospital days 

Cancer patients 

All nursing staff and support personnel were required beginning January 2001 to document each patient's rating of their pain intensity using a numerical scale, along with other vital signs with every routine patient assessment. 

Change in patient satisfaction and opioidrelated ADRs, including oversedation or respiratory depression requiring discontinuation of th eopioid or reversal with naloxone, in the 4 years before and 2 years after implementation of new pain management standards. 

Pre-intervention: 79 opinpatient hospital daysoversedation. Post-inte65,388 inpatient hospit16 oversedation eventincrease in the incidenADRs and cases of ov(p=0.01 and p=0.03 reof ADRs increased by (95%CI 1.08-2.07)67% analgesia within 1 houapproximately 25% wasatisfaction ratings incand after the NPTA pe

10

VA ESP - Management of Acute Pain in Inpatients 
APPENDIX E. Evidence Summary Tables 

Summary Table 3. Studies on the effectiveness and safety of patient-controlled analgesia for acute pain (KQ2) 

Study 

Design, 

setting 

Clinical 

condition/ 

baseline pain 

Author, 

Year 

Sample 

size Intervention/exposure of interest 

RCT, not placebocontrolled, in an ED 

86; 43 in each group 

Trauma patients, mostly fracture: 53.4% control, 74% PCA 

After baseline measures of VAS, BP, pulse, GCS, SaO2, respiratory rate, an IV cannula was inserted. Controls were given 0-10 mg morphine by IV, titrated by a nurse. Morphine was given at a rate of 1-2 mg/min until by patient's responses pt was comfortable. Pts were then asked to call for further analgesia if needed, and nurse was expected to check pt periodically per ED guidelines. PCA group pts were instructed in the use of the PCA, which 

administered a 5 mg loading dose with a subsequent bolus dose of 1mg and a lockout interval of 5 minutes. Pain scores and physiological measurements were made at 0, 5, 15, 30, 45, 60, 90, and 120 minutes. Patients were also given 50 mg of cyclizine to minimize nausea and vomiting. Recording of AEs were made by observation. At least 12 hrs after admission to a ward or discharge, patients were contacted by the researcher to complete a satisfaction questionnaire. 

The mean pain scorsimilar (4.8 and 4.8, Area under the curvconfirmed that there between the 2 groupTwice as much morpgroup, despite the smg PCA v. control: 1amt delivered over m4.03 mg/h control. AEs: PCA patients ns), most commonly There were no signifsatisfaction question

Evans, 200511

Fulda, 2005

DB RCT, placebocontrolled 

44; 22 in each group 

All had thoracic fractures: Unilateral rib fractures = 59% Bilateral rib fractures: 27%The mean injury severity score was 10.5 in the NMS group, 9.8 in the PCA group. 

Randomized to 2 groups: nebulized morphine (NMS) or control group (PCA morphine). The PCA group received nebulized saline every 4 hrs with PCA morphine; the NMS group received nebulized morphine every 4 hrs with PCA saline. Pain was considered controlled if VAS <=4 and patient stated 

pain was well controlled. Patients with uncontrolled pain after 30 minutes Patients in NMS group received additional PRN doses of nebulized morphine every 30 minutes up to 2 treatments, and had the PCA pump adjusted to provide PCA doses of saline every 15 min. Patients in PCA group had PCA delivery adjusted to include addition of 1 mg of morphine every 15 minutes on demand, and received 2 additional PRN nebulized saline treatments every 30 minutes up to 2 treatments 

The NMS group reqPCA group: the aver11.96 for the NMS ggroup (p<0.001). Alobservations, patienof increased sedatiolower sedation score0.56, p=0.03). Only 

exceeded sedation lPCA group exceedepatients had less mogroup as a whole, so Patients with NMS hheart rate, and a nonrespiratory rate comEffect on pain level wPCA morphine Mean pain score for pretreatment v. postNMS: 5.38 v. 3.52 vPCA: 5.73 v. 3.89 v

12

VA ESP - Management of Acute Pain in Inpatients 
APPENDIX E. Evidence Summary Tables 

Summary Table 3. Studies on the effectiveness and safety of patient-controlled analgesia for acute pain (KQ2), conti

Study 

Design, 

setting 

Clinical 

condition/ 

baseline pain 

Author, 

Year 

Sample 

size Intervention/exposure of interest 

Controlled CT at Univ Cincinnati 

34 enrolled; 10 excluded from analysis 

Significant thoracic traumatic injury 

Epidural analgesia vs. PCA Patients randomized to PCA received a loading dose of IV morphine 0.1 mg/kg before establishment of PCA. The infusion was titrated by a member of the acute pain service to maximize pain relief before handing over the control of the system to the patient. The PCA regimen used morphine 1 mg/ml in bolus doses of 2 mg with a lockout duration of 10 minutes. There was no background infusion. Thoracic epidural catheters were placed by an anesthesiologist in the epidural space between T5 and T7. A 3-ml test dose of lidocaine 1.5% with epinephrine 1:200,000 was then administered through the epidural catheter to exclude subarachnoid or intravascular location of the catheter. Sensory testing of appropriate thoracic dermatomes was performed 10 mintues after to confirm epidural placement of the catheter. The catheter was further dosed with an injection of fentanyl (50 ug) and 3 mg preservative-free morphine. Within 1 hr of placement, a continuous infusion of bupivacaine 0.25% and morphine 0.005% was initiated at a rate of 4-6 ml/hr using an infusion pump. A member of the APS adjusted the infusion rates to opitmize pain relief and minimize side effects. 

During the first 24 hrhad a significant redcoughing, compared After 48 hrs there wabtw the 2 routes of oOn day 3, the epidurreduction in pain scogroup, whose score same as for day 2. The epidural group's significantly lower th(p<0.05). PCA patients had a during the study pergroup had a continuepidural group had a PCA. Tidal volume continu(56% on day 3 compepidural group had a increase from day 1

Moon, 199913

Retrospective cohort study 

64, 32 in each group 

Multiple (3+) rib fracture from motor vehicle crash N fractured ribs: 5.6 epidural vs 4.4 PCA (p=0.01) Injury severity score: 21.6 epidural vs 21.9 PCA (p=ns) 

Patients who received IV PCA were able to obtain 1 mg of morphine every 6 minutes through the PCA pushbutton. The morphine could be increased by physician order. Epidural catheters were inserted in the thoracic region (T5-T9) with local analgesia (0.125 to 0.25% bupivacaine) and fentanyl (2.5 ug/mL), and the initial infusion rate was 5 to 8ml/h as adjusted by the Acute Pain Service. 

There was no differeepidural analgesia in of ICU stay, or lengtwith epidural analgeratings at all time intbaseline scores (diffin the PCA group, p-p<0.001 at various tdifferences between pulmonary, cardiac, 

Wu, 199914

VA ESP - Management of Acute Pain in Inpatients 
APPENDIX E. Evidence Summary Tables 

Summary Table 4. Studies on the management of acute pain in renal colic and biliary stone (KQ2) 

Study 

Design, 

setting 

Author, 

Year 

Sample 

size 

Clinical condition/ 

baseline pain 

Intervention/ Outcomes 

measured R

exposure of interest 

Cochrane systematic review, NSAIDs 

20 trials with 1613 

Most studies included only participants with renal calculi confirmed on subsequent testing, and excluded patients with negative results on followup tests. 

Trials compared one of 5 NSAIDS (diclofenac, indomethacin, indoprofen, ketorolac, tenoxicam), to 1 of 7 opioids (pethidine was used in 10 of the 20 trials). The intramuscular route was most commonly used for each drug type (10 trials), followed by the intravenous route (7 trials). 

Patient-rated pain and/or time, time to pain relief, need for rescue medication, rate of pain recurrence, adverse events. Major events were defined as GI hemorrhage, renal failure, hypotension, and respiratory depression. Minor adverse events were defined as GI disturbance without bleeding, dizziness, sleepiness. 

Patients receiving NSAIDthan patients receiving othough the differences won efficacy due to heteroanalgesia was significant0.75, 95%CI 0.61-0.93). More AEs with NSAIDs iespecially vomiting with pThe reviewers concluded opioids provide effective but opioids, particularly pincidence of vomiting and 

Holdgate, 200715

Prospective DB RCT comparing hydrmorphone v. meperidine in a tertiary care center with 93,000 annual ED visits. 

36 hydromorphone, 37 meperidine. 

Presumed ureteral colic 

Comparable doses of the 2 medications were administered at t=0. The patients were randomized to receive either 50 mg meperidine (M) or 1 mg hydromorphone (H) IV in a doubleblind manner. 

Remedication interval for patients requiring additional analgesia; proportions of men and nonresponders 

Baseline VAS pain scoretreatment groups at t=0. lower pain intensity levelgroup had significantly mgroup. Significantly fewepyelograms in the H grouthere were fewer admissgroup (25% v 49%, p=0.0AEs: there were more pvomiting in the M group cp=0.31. More patients o(22% v 11%, p=0.25. Thsimilar rates of drowsine

Jasani, 199416

VA ESP - Management of Acute Pain in Inpatients 
APPENDIX E. Evidence Summary Tables 

Summary Table 4. Studies on the management of acute pain in renal colic and biliary stone (KQ2), continued 

Clinical 

condition/ 

baseline pain 

Author, 

Year 

Study Design, 

setting 

Sample 

size 

Intervention/ Outcomes 

measured R

exposure of interest 

MurielVilloria, 1995

IM v. IV dipyrone 

Varied by intervention, 22-70 

Renal colic dipyrone 1g IM + placebo IV 

dipyrone 1g IV + placebo IM dipyrone 2g + placebo IM dipyrone 2g + placebo IV diclofenac 75mg IV + placebo IM 

Proportion of patients with >50% improvement 

Significant differences: dipyrone 2g IV > 1g IV at dicloefenac 75 mg IV > Idipyrone 1g IV > 1g IM a

17

Nelson, 1988

Rectal v. IV indomethacin 

Varied by intervention, 53-63 

Renal colic indomethacin 100mg PR 

indomethacin 50mg IV 

VASPI at 10' IV significantly lower than 

Supplementary analgesic

18

Rectal v. IV indomethacin 

Varied by intervention, 44-54 

Renal colic indomethacin 100mg PR 

indomethacin 50mg IV 

VASPI at 10' and 20': 

VASPI: IV significantly ldifference. Use of supplementary an(p=0.03). 

Nissen, 199019

Single-blind, randomized trial Biliary stone: subcutaneous injection of dihydromporphinone v. IV indomethacin 

42 Acute attacks 

of biliary stone pain 

Group D received 1 mL of dihydromorphinone and patients in Group I received 50 mg of indomethacin intravenously. The surgeon on duty conducted patient exam and provided information about the ongoing study. (Subsequently?) the attendant nurse provided the drug injection, but the examiner was blinded to the treatment. Pain was evaluated at baseline and at 10 and 30 minutes after drug injection. In cases of insufficient pain relief, a second injection was given. 

Pain (VAS) at 10 and 30 minutes after administering treatment 

N/total free of pain at 10 Group D: 2/21 at 10 min, Group I: 2/21 at 10 min, Mean scores at baselineGroup D: 71.8, 44.1, 14Group I: 68.5, 32.4, 15.Pain reduction within eacsignificant (p<0.01) wherthe two groups was not. AEs: 2 pts in each group D developed a red, itchininjection site. 1 in Group another in Group I exper

Uden, 198420

VA ESP - Management of Acute Pain in Inpatients 
APPENDIX E. Evidence Summary Tables 

VA ESP - Management of Acute Pain in Inpatients 

Summary Table 5. Studies on the effectiveness and safety of neural blockade for acute pain (KQ2) 

Author, 

Year 

Study 

Design, 

setting 

Sample 

size 

Clinical 

category; 

baseline 

pain 

Intervention/exposure of 

interest Outcomes measured 

Chudinov, 199921

Randomized trial in orthopedic hospital, Israel 

40 Hip fracture, 

undergoing surgery 

Psoas compartment block using 2mg/kg/body weight of 0.25% bupivacaine with adrenaline (0.8 ml/kg) and supplementary doses as required via catheter vs. no block 

Length of follow-up: perioperative period only (72 hours). Pain relief assessed by VAS. Adverse effects of the block 

The psoas compartmsignificantly less paioperatively, and also post-operatively. Prwho received the pspain control compar

Haddad, 199522

Randomised trial 

50 Extracapsular hip 

fracture 

Femoral nerve block inserted at time of admission using 0.3ml/kg of 0.25% buipivacaine vs. control group (no injection 

Mean pain score using VAS: pre-block and at 15 mins, 2 hrs and 8 hrs. Amount of analgesic administration within first 24 hrs of co-codramol, voltarol, pethidine. Incidence of respiratory infections, CVA, pulmonary embolism, deep vein thrombosis, urinary tract infection, skin breakdown, mortality, failed nerve block. 

Femoral nerve bloc

reduction in the meastatistically significanchange -2.6 v. -0.7) reduction -3.0 v. -1.2analgesic drugs admadmission was redugroup. Local or systoccur with the use o

Scheinin, 200023

Randomized trial, orthopedic hospital in Finland 

59 Hip fracture, 

undergoing surgery 

Lumbar epidural using bupivacaine and fentanyl inserted within 6 hrs of admission. Infusion rate adjusted according to patients requirements vs intramuscular opiate (oxycodone 0.1-0.15mg/kg) at 6 hourly intervals as necessary. All patients operated on using spinal anesthesia 

Length of follow-up for clinical outcomes was 3 days. Mortality for 3 years was determined using central statistic register. Pain relief as assessed by VAS (scale 0-100). Ischemic episodes as determined by continuous electrocardiogram recording; nocturnal oxygen saturation; itching; nausea; quality of sleep; mortality. 

Pre-operative pain sdiffer (p=0.42) continbupivacaine plus fencontrols who receive(mean 42), although were significantly (pepidural group (meaintramuscular opiatecomplications specif
APPENDIX E. Evidence Summary Tables 

Summary Table 5. Studies on the effectiveness and safety of neural blockade for acute pain (KQ2), continued 

Study 

Design, 

setting 

Clinical 

condition/ 

baseline pain 

Author, 

Year 

Sample 

size 

Outcomes 

measured Intervention/exposure of interest 

Halbert, 2002 #1428

SR of 12 controlled trials that reported phantom pain as an outcome 

Included 12 trials, 

total 375 

patients 

(both men 

and 

women), 

ages 47-

75. 

8 trials of treatment of acute phantom pain with preoperative, intra-operative, and early (<2 weeks) postoperative interventions 

8 trials on phantom limb pain studied epidural treatments (3 trials); regional nerve blocks (3); calcitonin (1); and transcutaenous electrical nerve stimulation (1). 4 trials on late postoperative pain studied transcutaneous electrical nerve stimulation (2) and Farablock (a metal threaded sock) and ketamine (1 trial each). In 8 preop/intraop/early post-op trials, the interventions included epidural anesthesia (3 trials), regional nerve blocks (3), intravenous calcitonin (1) and TENS. Controls received a placebo consisting of a saline infusion or epidural anesthesia consisting of on-demand opioid analgesia. 5 trials used opioid analgesia, and 1 trial used sham TENS with and without chlorpromazine. Trials that used epidural anesthesia commenced 18-72 hours before surgery. Blockade anesthesia commenced during the operation or postoperatively. 4 trials of late postop interventions included TENS, Farabloc, vibratory stimulation, and infused ketamine. 

Effect on phantom limb pain at various time points up to 12 months postamputation 

Up to 70% pain after aevidence fclinicans wEvidence oregional nevibratory s

support for 

24

VA ESP - Management of Acute Pain in Inpatients 
APPENDIX E. Evidence Summary Tables 

VA ESP - Management of Acute Pain in Inpatients 

Summary Table 5. Studies on the effectiveness and safety of neural blockade for acute pain (KQ2), continued 

Author, 

Year 

Study 

Design, 

setting 

Sample 

size 

Clinical 

condition/ 

baseline pain 

Intervention/exposure of 

interest Outcomes measured 

Knoop, 199425

Randomizedprospective, nonblinded clinical study, convenience sample; inner-city and community hospital ER 

30 Patients had 

3rd or 4th finger injuries including and distal to the proximalinterphalangeal joint that required digital anesthesia. Injuries included lacerations (67%) and infections (27%). 

Digital blocks and a metacarpal block were performed on each patient, in randomized order. Additional anesthesia was given and noted when required for all patients. After a period of no less than 10 minutes, the patient was treated in a mannger consistent with the injury (ie, sutures, incision, and drainage). 

Patients immediately rated pain associated with each technique on a nonsegmented VAS. Efficacy was assessed by requirement for additional anesthesia and anesthesia to pinprick. Time to anesthesia was assessed after each block in 23 patients. Patients were asked which technique they thought was more painful or if there was no difference between the 2 techniques. Responses were recorded for 10 minutes. 

Digital block was lesblock by both VAS abut the differences dsignificance. There scores of the first blosecond block. Mean for digital block, and block (p=ns). 40% of patients ratepainful, and 7% notebetween the blocks Digital block was foumetacarpal block faiseven of 30 metacarwith one of 30 (3%) When requirement fassessed, digital blotime (29 of 30 blockswas adequate 87% p=ns). Time to anesthesia afound to be significacompared with meta2.82 minutes vs. 6.3
APPENDIX E. Evidence Summary Tables 

References in Appendix E, Evidence Summary Tables 

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ureteral colic. Academic Emergency Medicine. Nov-Dec 1994;1(6):539-543. 

VA ESP - Management of Acute Pain in Inpatients 
APPENDIX E. Evidence Summary Tables 

VA ESP - Management of Acute Pain in Inpatients 

17. Muriel-Villoria C, Zungri-Telo E, Diaz-Curiel M, et al. Comparison of the onset and 

duration of the analgesic effect of dipyrone, 1 or 2 g, by the intramuscular or intravenous 

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Scandinavica. Apr 1988;154(4):253-255. 

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