​An article published in the October issue of the Journal of PeriAnesthesia Nursing concludes that using multidimensional pain assessment tools can help improve pain care outcomes in the perianesthesia setting. The authors described how the "pain as a fifth vital sign" (P5VS) initiative—a unidimensional approach to pain management that involves the use of a numerical rating scale in which patients rate their level of pain from 0 (no pain) to 10 (worst possible pain)—has failed to improve the quality of pain care in the United States despite widespread adoption, according to a growing body of literature. Reasons for failure of P5VS, according to the authors, include the fact that the experience of pain is "multidimensional with sensory, affective, cognitive, and functional components" that cannot be captured by rating only severity; that the subjective nature of the scores makes it hard for patients to accurately describe their pain levels; and that many care systems link treatment (e.g., opioid dosage) to specific pain scores. The latter practice can deter nurses from conducting thorough pain assessments and evaluations of patients' functional statuses. In a new approach, the authors note, several organizations, including the American Pain Society (APS) and Joint Commission, have begun advocating for a multidimensional approach to pain management. In guidelines released in 2015, APS recommended incorporating additional elements of the pain experience. This practice includes evaluating "pain's effect on physical function, ascertaining pain-related emotional distress, determining the impact of pain on sleep, and inquiring about past pain treatments and level of opioid tolerance." The guidelines also recommended performing a comprehensive evaluation of the patient before surgery to determine the patient's medical and psychological illnesses, documenting previous pain management regimens and responses, and determining whether the patient has a history of chronic pain and substance abuse. Joint Commission now also requires accredited hospitals to establish policies and procedures for comprehensive pain assessment (see HRC Alerts, June 28, 2017: Joint Commission Revises Pain Management Standards to Address Risks of Opioid Use, and the related  HRC Alerts, September 6, 2017: You Have Questions, They Have Answers: Joint Commission Releases Rationales behind Revised Pain Management Standards). Multidimensional tools that may improve outcomes include the Clinically Aligned Pain Assessment Tool (CAPA), which prompts clinicians to have structured conversations with patients about their pain; the modified Brief Pain Inventory (BPI), which contains three items to measure severity of pain and five items to measure pain interference; and the revised APS Outcome Questionnaire, which assesses pain severity and pain's impact on activities, sleep, and emotions and asks about pain-medication-related side effects.

HRC Recommends: Patients should receive an individualized plan for managing postoperative pain, including pain that may persist after discharge. This begins with a comprehensive assessment of the patient and discussion of goals and expectations before planned surgery. Clinicians should consider multimodal pain management, which may include nonpharmacologic modalities, nonopioid pain medications, or opioid-sparing techniques, whenever appropriate. Care coordination among surgeons, anesthesia professionals, hospital-based providers, and primary care physicians may be necessary, and consultation with pain management specialists should be considered in complex cases (e.g., patients taking long-term opioids before surgery, patients with kidney or liver disease).