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.

Score	Severity	Parameter (Observed)	Parameter (expressed)	Action
0	No pain			Complete procedure
1	Minimal	Facial creasing, pursing lips, change in tone of voice, transient stop in conversation. No verbal complaint.		Complete Procedure
2	Mild	Grimace, moan, groan, sigh. Breath holding. Verbally mentions pain (but not as ‘complaint’)		Complete procedure with reassurance
3	Moderate	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
	Moderate	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)
4	Severe	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. http://successinhealthcare.blogspot.co.uk/2014/02/kahneman-colonoscopy-and-goole.html

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

©M HEMADRI

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Innovations in a small hospital

Have you heard of Goole Hospital? If you have not heard of it, that is not surprising. We generally don’t want you to hear about it/us.  It is a small hospital with about 30 beds and we do not do brain transplant.

We have a minor injuries unit, some medical in-patients, elective services in ophthalmology, orthopaedics, general surgery. There are outpatients and other services – you can check out the website http://www.nlg.nhs.uk/hospitals/goole/

What fascinates me is the number of innovations that have happened in Goole. Why it happens could be the subject of another blog post.

I am defining innovation as, ‘use of a better and, as a result, novel idea or method’ (Wikipedia).

Goole Innovations

Here I write about a dozen innovations that I have seen or been involved in at Goole.

1)      No clinic letter Clinic notes faxed to GPs as is

This when the general surgery clinic’s doctors’ handwritten notes are faxed to the general practitioner (mostly within 24 hours) instead of a letter first dictated then typed and then cross checked before signing and sending. Saves a load of secretarial time and money.

2)      Tests before OPD (USS OGD Flex Sig)

When we know by reading a general practitioner’s letter that the patient would undoubtedly need a particular test, such as an ultrasound scan, gastroscopy or a flexible sigmoidoscopy the doctor who vets the letter orders the test so that the result of the test is available for discussion at the patient’s first out-patient clinic consultation. Allows sensible discussion, often gives answers.

3)      Same day pre-assessment for general surgery and endoscopy patients

When the doctor tells the patient ‘you need a surgical procedure’, the patient if they have the time are pre-assessed at the same first surgical clinic visit. A kind of a one-stop service. Saves a lot of time for patients. We try to do this as often and as many patients as we practically can.

4)      Single Visit General Surgery

For general surgery patients who are suitable for day case surgery the Goole Single Visit pathway offers for suitable patients the option of visiting the hospital just once. Consultation and operative surgical procedure (occasionally some smaller additional investigations) all done in the same visit. Lumps and bumps right up to gall bladders.

See this link http://successinhealthcare.blogspot.co.uk/2011/12/single-visit-surgical-service.html that blogs about the single visit service

5)      Laser Haemorrhoidectomy

Formal surgical operation for piles done with local anaesthesia and laser with patients discharged in two hours. We have been doing this for a few years now. Brief blog about that can be found at http://successinhealthcare.blogspot.co.uk/2011/11/laser-surgery-for-piles.html

6)      Entonox for colonoscopy

Entonox, also known as gas & air can be used instead of sedation for colonoscopy. That is neither special nor surprising. In Goole, at the last look, we found approximately 35% of our colonoscopy patients opted for Entonox when the general published number is 17%. All I can say is our patients and staff are very special.

7)      Straight to test two week wait colo-rectal cancer referrals

Overwhelming majority of patients referred as two week wait cancer referrals end up having a colonoscopy. We have a system where suitable patients have their first consultation and colonoscopy at the same visit. http://www.nlg.nhs.uk/news/one-stop-service/

8)      Own reporting software for endoscopy

External software involves purchase cost, maintenance cost and annual licensing costs. We have created our own reporting software with Microsoft Infopath which was already available in trust computers. We have been using this for a few years. Spending your money responsibly, eh?

9)      Single length endoscopic accessories (0 error)

We use the colonoscopy length accessories for colonoscopy and gastroscopy. This has resulted in zero error hence zero waste (since there is no possibility of opening a gastroscope length accessory for a colonoscopy procedure)

10)  Home enemas

Patients who are for flexible sigmoidoscopy need an enema. To have someone unknown administer an enema in an unfamiliar environment and then have to use the unfamiliar toilet can be bothersome. We ask patients if they want to administer the enemas themselves in the comfort of their own homes.

11)   In-situ simulation training

First in-situ simulation training with two scenarios, two trainers, one volunteer ‘patient’ and a professional actor, in our organisation with three hospitals. Even before our nearest tertiary hospital could do it (they have since done it)

12)  Local Anaesthesia option for most inguinal and umbilical hernia repairs

Once the patient is considered suitable the patient has the choice to go for local anaesthesia (with or without sedation) or a general anaesthetic. A large number go for local anaesthetic repairs.

13)  Synchronised test-opd

When routine follow up ultra-sound scans are needed to monitor a situation, we used to get them done a couple of hours earlier than the clinic appointment time. Latest information available. One visit instead of two for the patient. We used to do this typically for patients who were being monitored for abdominal aortic aneurysms.

I said a dozen things done differently at Goole but have listed 13; that would be typical of Goole, we try and often tend to over deliver.

There are a number of innovations from our colleagues in orthopaedics, ophthalmology and other departments.

You will not hear too much from Goole, the people there are a bit shy of fame, a bit skeptical about awards, a shade reluctant to talk about themselves; it is a unique micro-culture - more on that later. There are very specific reasons why innovation happens at Goole (though I do not have too high a regard for CQC ratings you may be interested to know that Goole Hospital scores all greens ‘good’ www.cqc.org.uk/sites/default/files/new_reports/AAAA1778.pdf  for its services, we at Goole are neither bothered nor surprised about this).

At this point I have to say that I am one of the very few variant ones for Goole, talking and blogging about these things, I suspect my team often wonders why I am so vain.

Many hospitals in the country could be doing one or more of the above, but I do wonder if all these things happen in a small hospital.

©M HEMADRI 

Follow me on twitter @HemadriTweets

PS: We follow Noble prize winner's Kahneman's methods to improve our patients' experience, I have already blogged about this http://successinhealthcare.blogspot.co.uk/2014/02/kahneman-colonoscopy-and-goole.html

Kahneman, Colonoscopy and Goole

The Goole way of improving patient experience of colonoscopy

Colonoscopy and pain

All of us are well aware that despite our collective immense experience, colonoscopy can be a painful procedure for our patients. That is the reason we use analgesics. At this time influencing the experience happens by the sedation (midazolam) we give (influencing the perception, awareness and causing possible amnesia for the duration). Of course, the patient always has a better experience if our technique is good (minimum inflation, not going into loops, undoing loops early, change of position, abdominal pressure, lower total duration of procedure etc). Nevertheless patients can experience pain.

The pain obviously causes immense distress to patients, it also causes complaints. More relevantly pain may cause the patient to decline colonoscopy in the future. For some patients due to the nature of their disease repeat colonoscopy becomes essential and pain or unpleasant experiences puts these patients into distress even at the thought of considering colonoscopy. Patients may also colour the expectations of their family and friends regarding colonoscopy.

Kahneman and clinical psychology

The 2002 Nobel prize winner Daniel Kahneman has done important work on patient experience and its relation to the patients' willingness/readiness for further colonoscopy in the future if required. My understanding of what Kahneman says is that the total duration of the procedure, the highest rating of pain during the procedure or the duration of high levels of pain matters much less than the degree of the pain experienced at or towards the end of the procedure. For instance this means a patient with a 10 minute colonoscopy who was relatively comfortable for 9 minutes but had significant pain the in the 10th minute reports a worse experience than a patient who had a 20 minute colonoscopy with relatively severe pain for the first 17 minutes and no pain in the last 3 minutes. In fact in Kahneman's experiments they deliberately kept the colonoscope in place for extra 2 or 3 minutes so that the patient can have a pain free ending.

The lessons to us are of course self-explanatory - irrespective of the duration of the procedure or the degree of pain we should not take out the scope quickly and allow a pain/discomfort free period before the end of the procedure.

Kahneman explains this as the difference between experience and memory - with the message being what happens in the end is remembered more as the memory (rather than the totality of the duration of the experience even if that was painful/unpleasant).

The Goole Translation

We wanted to translate this into an even more tangible improvement of patient experience than just a slow withdrawal.  We wanted to go forward from the described lack of negative experience to the establishment of a positive experience. If Nobel Laureate Kahneman says the end of procedure experience is counted as memory we wanted to try to deliberately aim for and deliver a positive memorable experience.

At colonoscopy one of the main roles of the nurse who supports the patient is the reassurance role. Till the scope reaches the caecum the nurse has a reassurance role (‘you are doing fine’, ‘its nearly done’, ‘take nice and easy deep breaths’, ‘pass some wind out & you might feel better’ etc) - this is the normal role for the nurse in any endoscopy unit anyway and we do it as well. Once the scope reaches the caecum and completes the examination of caecum/terminal ileum, this reassurance role generally diminishes as the patient feels less pain, less anxiety etc. At this point I declare to the patient and the staff 'we have reached the end we should be getting out soon'. In Goole that statement would be the cue for the nurse to reduce the reassurance role and deliberately start a conversation with a high quotient of humour with the patient. The explicit aim is to try and make the patient laugh.

There seems no obvious downside or specific risks noticed yet. Important to remember that it is the nurse who supports the patient who engages in humour. The endoscopist and the nurse who supports the endoscopist remain extremely focussed and serious on completing the procedure safely.

We find that the patients end up in a really good mood when we are able to make them laugh. The trick is for the nurse-patient conversation to elicit a laugh. On the contrary, nurse-nurse or nurse(s)-endoscopist or even endoscopist-patient conversation eliciting the laugh from the patient is in my view is not as effective. The nurse-patient conversation resulting in a laugh is the crucial element; anyone else laughing may not be liked by some patients especially as the patient could be at the end of an unpleasant procedure.

In my conversations with people in the know, I learn that on the way to the caecum when the patient is experiencing distress/pain it could be okay to distract by attempting a social conversation but not with the intention of humour as that could end up as 'the memory' ('they joked while I was in pain'); the intention to humour is only after reaching the end point while making a slow withdrawal provided the patient does not have pain on withdrawal (if there was pain on withdrawal, then the reassurance role becomes important again)

It seems like common sense. Apart from a potentially great patient experience we find that the atmosphere in the procedure room becomes very enjoyable. It develops a good relationship between staff members. We have only just started doing this. I write my initial impressions and not any definite long term observations. This is not based on research, it is a simple description of what we do and what we feel about what we do on the matter of influencing patient's memory of colonoscopy.  I just wanted to share this simple and in my view, elegant humour based intervention to improve patient experience. You may want to try it with your patients, get your nurses to do this. Not every nurse will agree or be willing to go with this. That is okay, best to work with the willing.

Kahneman has proven the science - I have just added humour to it.

©M HEMADRI

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Guarantees in Healthcare

I would like you to take a moment to think about what is the longest guarantee period offered for a product that you know of. Months, years, decades? What about life-time guarantee? For instance Toyota offers an 8 year guarantee for their Prius battery for the electrical motor part of their hybrid system. Some manufacturers and some body works repairers offer life time rust proof guarantee. Pizza companies say that you can have the pizza for free if it does not reach you within a defined time after your order. Well you can surely name a few more yourself.

Here is a jaw dropping guarantee. 2000 years.

Yes, you read it right The Sweet Little Sugar Softener offers a 2000 year guarantee. Yes that is offered for a product that is very simple. Okay, I am not sure if any of us are going to be around for 2000 years to vouch for this. But just imagine the confidence of the manufacturers in their product that they are able to offer it. It is a product made by simple artisans in rural America, not highly educated, with no great facilities etc


Guarantees in Healthcare

Health care is full of educated, highly intelligent and motivated people. Many if not all clinicians would have two post-graduate degrees. Healthcare managers and insurers are very large players in terms of the total money spent on healthcare especially in the western world. What kind of guarantees can healthcare offer to patients? As far as I know, none. In fact, professional bodies may not look at you very kindly if you started offering any guarantees, they will come down on you with a tonne of heavy scientific bricks and with a high moralistic tone accuse you of potentially misleading patients. Why is that? Why is it that healthcare which consumes so much of our resources unable to offer any sort of guarantees to our patients?

It is high time that we started backing our intelligence, education and skills and experience to think about what guarantees we can offer our patients and how we can make those guarantees work. We then need to put some money to back those guarantees. Doctors should perhaps take the lead on this one. Doctors always claim that they are consistently in the top 2% of the top performers in the society - well that is indeed true. If the top 2% performers cannot guarantee any of the activity they do and back it with some money we do need to either question their performance or their motives.

Healthcare needs some guarantees, patients need some guarantees. Yes, you healthcare folks, time to up your game, I know you cannot yet reach the level of guarantee offered by rural native American artisans but surely you could start with something small. How about no charge for patients if their bowel anastamosis leaked? How about completely free care if you did not meet the expected discharge date? How about paying a penalty to the patient every time you cancel or postpone their appointment/operation/etc.

Healthcare just dazzling and blinding people with asymmetrical power, high intelligence and skills is not simply good enough any longer. It has to be matched with some performance guarantees.

Being the change you want to see - the oft repeated Gandhian saying; on that basis let me go first.


OFFER OF MONEY BACK GUARANTEE IN HEALTHCARE
(possibly for the first time in the world)

One day the whole of healthcare especially doctors including me may be able to offer guaranteed clinical end results; right now it seems we cannot. So what can I guarantee can I give my patients? Before we get into that let me also explain that I work in the NHS on a salaried basis in a surgical department. NHS allows me to do private practice but I am not in regular/routine private practice. I cannot as an NHS doctor offer any individual guarantees to my patients. I am like the rest of the British people, own the NHS but do not run it. However I can offer some guarantees to my potential private patients.

Here are the guarantees I am willing to offer to any private patient who cares to find me and pay me a fee for service (self paying private patients).
Open primary inguinal hernia repair: if you have a recurrence within 3 years I will refund you the my fee i.e. the surgeon's fee.
Colonoscopy: if I do not reach the caecum (provided it was not poor bowel preparation or a confirmed bowel narrowing) and hence you had an incomplete colonoscopy I will not charge you my personal fee for the procedure.
Obviously all other charges will apply, have to be paid for and not be refunded.

As I have already said, right now I am not in active private practice. But if there were any patients who paid me privately for these two procedures that is the money back guarantee I am able to offer. If there were takers for this service/offer I might be stimulated to think of what further guarantees can be designed in healthcare.

What is important is if many others in healthcare provision are able to offer firm money back guarantees in healthcare. That might be a disruptive innovation in clinical provision. Let us go for it.

What are the guarantees that you are able to offer your patients?


Update: 1 Nov 2012: W Fischer informs me that there are guarantees in healthcare at Geisinger, Danville, PA since 2006. Very nice to know. So obviously I am not the first or the only. Here is a write up on their warranty: http://www.ihi.org/knowledge/Pages/ImprovementStories/GeisingerWarrantyonCABGSurgerySignalsCommitmenttoExcellence.aspx There are press stories about it, find it on the net. They do not seem to pay the patients any money back (I suppose that will be an issue for the insurers) but they do not charge the insurer to fix any complications.

©M HEMADRI 

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