Hospitals Try Pain Mitigation Alternatives

Pain mitigation techniques and tools can lead to greater patient satisfaction and higher HCAHPS scores, but the costs vary widely and must be weighed carefully.

Deb Bruene, MA, RN-BC, a nursing practice leader and educator at the University of Iowa Children's Hospital, has an exercise she likes to perform for clinicians about the lasting emotional effects of needle pain experienced in childhood.

"I ask the class for personal experiences," she says. "Everyone there almost always has a story about a child who had a bad experience with a needle, and how this experience impacted that child's care."

Recently, one of Breune's students told a story about a young woman who had been traumatized by receiving painful IV treatments when she was younger. The woman is now afraid to become pregnant, believing herself unable to withstand the pain of delivering a baby. 

This example may be extreme, but data demonstrates that people are more likely to avoid care when they are afraid of pain, says Peggy Riley, RN, MN, MPH, pediatric pain clinical nurse specialist at the University of Wisconsin Hospitals and Clinics in Madison.

"Needle pain is one of the most common kinds of pain people experience as kids," she says. As a result of forming bad associations between healthcare and pain, people often put off annual physicals and maintenance healthcare. And these anxieties often persist through adulthood.

"On the radio this morning, the talk show hosts were talking about getting their flu shots, and they said they were afraid they would wimp out and not get them," says Bruene. "That's the experience people often have."

Pain Mitigation Linked to Patient Satisfaction

Efforts to lessen or avoid negative patient experiences, including pain, are getting greater attention as the influence of HCAHPS scores on reimbursements grows.

"We seek to minimize pain as much as possible," says Lisa Dabby, MD, an attending physician in UCLA Medical Center's emergency department in Santa Monica. Pain mitigation methods she uses include:

• Liquid stitches, a dermal adhesive sold under the brand name Dermabond, that is used in place of traditional stitches
• Administering vaccines, pain killers, and other medications through nasal sprays or transdermal patches rather than intravenously
• Using a topical anesthetic prior to starting an IV or administering an injection
• Using ultrasound-guided IVs and vein finders to reduce the number of failed venipuncture attempts

Both Riley and Bruene have also had success with pain-blocking devices such as Buzzy Bee and Sofstic, which numb an area of skin by using vibrations and cold.

Proper use of painkillers can improve patient experience as well, says Bruene. She recounts the story of a child having a lumbar puncture prior to chemotherapy. The child's mother never used frightening words like "spinal tap." Instead she told him he was going to have a "back check."

The child received topical numbing agents and procedural sedation, and was not aware he was experiencing a procedure that is usually considered painful. Because the child's mother acted as though the procedure was routine, the child never thought to be afraid.

Distraction is an effective option in many cases, says Riley. "It can be something you have with you, it could be a picture on the wall." Riley often asks patients to count how many triangles they see in a drawing or painting, or asks parents to read from a book they brought.

But pain reduction methods have their limits.

Distraction can be fleeting.

Topical pain-relieving creams and sprays mitigate only surface pain, says Riley. "[Topical medications] provide relief as the needle pokes into the skin, but not as it goes into muscle." And then there's the wait. Ultrasound vein finders take "maybe a minute" extra to use. The wait for creams and sprays to take effect can be as long as 20 to 30 minutes, says Dabby.  That raises questions about throughput.

And there is the matter of effectiveness. Some of the methods touted as less painful only work on minor or moderately severe injuries. Liquid stitches, for example, should not be used on injuries larger than two inches in diameter, or in high-tension areas. "It should be an area that needs one stitch or two," says Dabby. Liquid stitches should not be used on a large gash or on surgical wound.

Wide Cost Variations
In addition to the cost of waiting, the cost of pain-mitigating hospital supplies can vary widely depending upon negotiating power, novelty, and availability of the particular product.

"I would say for the most part… liquid stitches are at least a good 20% less expensive [than traditional stitches]," says Lori Pilla, vice president of strategic alliances, custom contracting and clinical advantage at Amerinet, a group purchaser in St. Louis.

Adam Higman, vice president of Soyring Consulting, a healthcare efficiency consultancy, says he's usually found that Dermabond is more expensive than traditional stitches. "[The price is] $20-25.00 per unit on the Dermabond," as opposed to between $2.00 and $5.00 for most sutures, although some specialty sutures can be much more expensive. Higman adds that liquid stitches require less labor and time, which can offset the supply cost.

When purchased through a group purchaser, vein finders can be as inexpensive as $1000 each, although they are usually "of the realm of $11,000 to $15,000 a piece, if not mistaken," says Pilla.

The same wild variability in cost can be found in clinician training.

Marshall Maglothin, MHA, MBA, a Washington, D.C.-based former executive director of health systems and physician practices and now an independent consultant, designs training clinical programs for recognizing and treating pain. Usually, the programs he designs cost about "$20,000 to $40,000," he says, and can be completed online with interactive tools, at the clinician's convenience.

"Pain control didn't used to be big deal in the ED," he says. "Clinicians didn't used to be sensitive to pain. I think this has improved."

Maglothin says the demand for training is growing among hospitals, and that clinicians benefit from making patients more comfortable. "Pain makes it harder to work with the patients."

Pilla says that avoiding pain is good for the bottom line. "The newer pain-reduction methods tend to be a little more expensive up front, but in the bigger picture, the total cost model, they save money." Improved pain control can lead to better HCAHPS scores, she says.

"You need to look at total picture and cost of delivering care. Reducing pain eventually reduces costs," she says.

Bruene also believes that the benefits of decreasing pain outweigh the costs. "As healthcare providers, we all believe that first we must do no harm. When we know the long-term implications of needle pain, I don't understand why we would not use these [tools]."