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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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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