Monday, 25 May 2015

Colonoscopy Pain Score - How I do it

Colonoscopy is often a painful procedure – the duration of the pain or the intensity of it varies from patient to patient and for the same patient for procedure done at different times. The pain also depends on operator experience. What goes on in the patient’s life external to their physical/mental health also plays a part in the patient’s behavioural interaction during endoscopy. Hence, there are patient factors, endoscopist factors and environmental factors at play.

Assessing the pain during the procedure is the responsibility of the endoscopists and the endoscopy nurses. Endoscopy nurses are thought to be a ‘third party’ in terms of assessing patient comfort. The patient comfort assessment takes the form of the Gloucester score. 

The Gloucester Scale takes into account the frequency and duration of discomfort and any distress it might cause the patient; it is often reported as
Comfortable – talking / comfortable throughout
Minimal – 1 or 2 episodes of mild discomfort without distress
Mild – more than 2 episodes of discomfort without distress
Moderate – significant discomfort experienced several times with some distress
Severe – frequent discomfort with significant distress
Numerical rating of 0 to 4 are assigned for the above.

The difficulty for colonoscopists and endoscopy nurses is that the Gloucester scoring scale is subjective and acts as a post-event record rather than an intra-procedure guide. In other words how to decide on how to score and while the patient is having a particular score during the procedure what to do about it? The scoring system, I feel, is currently is static and slightly retrospective. A scoring system, in my view, should be current and a guide to action.

At a human emotional level the idea that a medical procedure could cause or causes distress (defined as extreme anxiety, sorrow or pain) in a patient is something that is very difficult to cope for most clinical practitioners in healthcare. It would be better for any assessment or score of such distress to be defined (parametered) and linked to action so as to help the practitioner. This is probably the intention of the Gloucester score anyway but it is not explicit from the scoring system chart or table.

As an endoscopist I reflect on how and why I have been scoring patients the way I do and this is what I find myself doing.

0 – No pain Comfortable – no visible evidence, if conversational no change in tone or speed of conversation

1 – Minimal pain – facial changes such as crease lines, licking the lips, pursing the lips, in white patient’s skin turning pink or red. If conversational, tone of voice changes or conversation transiently stops. There may be changes in the breathing but difficult to detect. Patient does not complain explicitly.

2 – Mild pain – facial and audible changes (grimace, moan, groan, sigh)  Conversation stops for a longer period. Vocally mentions (not complains) about discomfort Slight holding of breath Conversation restarts with reassurance

3 – Moderate pain – Patient asks you to stop temporarily due to pain. Patient explicitly states that they have pain. There is a needed top up of IV medication. If Entonox is used, then having to wait for pain to pass and the patient to give permission before continuing procedure again. Needing to change position to resolve or reduce pain. Patient withdraws consent due to a combination of predominantly anxiety and less predominantly pain (pre-existing anxiety must be present preferably with evidence such as tachycardia on admission or pre-procedure or patient explicitly expressed anxiety, or on regular medication for anxiety).

4 – Severe pain – Pain after iv top up medication, attempts to unloop, changes of patient position or (especially if Entonox) several patient guided stop-starts.  Patient withdraws consent due to pain and the procedure is abandoned. Simple reason, if the patient is in severe pain we have no business to continue.

In practice, there is no difference between 0 and 1 i.e. no pain and minimal pain; once a scope is inserted and insufflation begins there is some degree of discomfort and pain is bound to happen and at the level of 0 or 1 it simply means that the patient is not concerned about it. No reassurance is needed for the purpose of pain.

In practice if reassurance is needed, offered and sufficient to continue the procedure after a patient mention or staff recognition of pain then it is mild pain.

If the patient shows features of what is assessed as moderate pain then top up intravenous medication is given or if Entonox wait till patient gives permission to proceed. For the purpose of scoring if top up intravenous medication was given or in the case of Entonox if there was a need to wait for the patient to permit explicitly to proceed then it is scored as moderate pain. If the patient withdraws consent due to mostly anxiety (on the assumption that however anxious the patient having started the procedure pain would be a trigger to withdraw consent and probably not just anxiety alone) then the scoring would still be ‘moderate’ pain.

If the patient is in severe pain the procedure is abandoned (and for the purposes off scoring, if procedure had to be stopped due to pain then it is severe pain)

This is the way I use a broadly subjective retrospective pain score into a mostly objective intra-procedure guide by a hopefully logical three way dynamic link of defined parameters, action taken and score.

Parameter (Observed)
Parameter (expressed)
No pain

Complete procedure
Facial creasing, pursing lips, change in tone of voice, transient stop in conversation. No verbal complaint.

Complete Procedure
Grimace, moan, groan, sigh. Breath holding. Verbally mentions pain (but not as ‘complaint’)

Complete procedure with reassurance
All of the above and need to change position
All of above and patient explicitly complains of pain with a need to stop procedure temporarily.

Complete procedure with additional medication

Anxiety explicitly stated on admission
Taking medication for anxiety
Physical features of anxiety eg. tachycardia
Patient withdraws consent due to a predominance of anxiety made worse by pain
Abandon procedure (after additional medication was tried)
Pain not relieved by top-up iv medication
Pain not relieved by change of positions and attempted unlooping. If Entonox, then Pain not relieved by waiting for patient to guide us to proceed.
Patient withdraws consent
Abandon procedure

By having a link between observable defined parameters and scoring I feel I am reducing my potential bias in the manner I might score. By linking score parameters to action I feel I further reduce the bias, I also feel this is able to offer better decision making for myself. A pre-defined parameter-outcome link makes operational sense and ensures ease of process.

These are all based on self-reflection and observation of my own practice, I did not set out to practice this way, I observed that I am practicing in this manner.

Then there is an issue of ensuring a better patient memory of the procedure irrespective of how uncomfortable the procedure actually was. This is achieved by slow withdrawal, in addition I have already written about the explicit use of humour if possible and appropriate, this is important for all the scores.

Perhaps all endoscopists are already doing this, may be not explicitly, in which case this was my excuse to write a blog.


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