Is Pain Still the Fifth Vital Sign?

Screening for pain is an important part of the nursing role in many different types of healthcare situations, from routine check-ups to post-surgical assessments. For two decades, from approximately 1996 to 2016, many organizations adopted the practice of treating pain as the fifth vital sign in order to give it increased importance within clinical practice.

This standard of care is no longer promoted by organizations with significant influence in the healthcare community, due to a multitude of concerns about its effectiveness (and possible dangers). Let’s discuss the history of using pain as a vital sign, and why there have been changes.

When Did Pain Become the 5th Vital Sign?

The concept of using pain as the fifth vital sign was introduced in 1995 by then-President of the American Pain Society, Dr. James Campbell. He proposed elevating pain assessment to the same level as other crucial markers of a patient’s status: respiratory rate, heart rate, blood pressure, and temperature. In 1996, the American Pain Society began formally promoting the concept in a broad campaign aimed at improving pain management for patients across the U.S.

Shortly after, in 1998, the Veterans Health Administration (VHA) launched their National Pain Management Strategy, including a “Pain as the 5th Vital Sign” Initiative. The strategy mandated pain screening of all patients using a numeric pain scale.

Continued Implementation of Pain as the 5th Vital Sign

In 2001, the Joint Commission (TJC) implemented standards for pain assessment and management. Materials presented to accredited organizations included examples of how to include pain in the group of vital signs.

Soon after, the Centers for Medicare and Medicaid (CMS) developed patient surveys that included questions about pain management during hospital stays. Legislation passed in 2005 linked patient surveys to reimbursement rates, creating a direct connection between a patient’s reports of pain intensity and the facility’s finances.

Broader History of the Fifth Vital Sign in Healthcare

Though this confluence of events, campaigns, and legislation influenced the widespread use of pain as a vital sign, it isn’t the whole story. The foundation for the approach had been laid throughout the 1980s and 1990s. During these decades, pain became increasingly seen as a subjective phenomenon with varying sensory intensitywhich providers had a moral and ethical obligation to manage as a primary objective.

For example, a nurse responsible for managing a patient’s pain might try to bring it from a reported seven to a three on a numeric scale—-even if the solution was short-term (for example, with opioids) and could potentially have detrimental long-term effects. Gathering data about pain along with the other vital signs fit into this framework because it allowed for an efficient, standardized approach to lowering reported pain levels.

The Results of Treating Pain as a Vital Sign

When pain is conceptualized as a vital sign, it’s seen as a crucial marker that must be addressed, similar to a high blood pressure that requires medical intervention. However, prioritizing a short-term decrease in the intensity of pain can have unintended negative effects, such as over-sedation, adverse reactions, and addiction. The approach can lend itself to reducing the experience of pain to a number that the provider is responsible for lowering (sometimes according to an algorithm or pain protocol), despite potential harm.

One hospital reported that after implementing a numerical pain treatment algorithm, patient satisfaction with pain management did, in fact, improve. However, because opioid analgesics are a common means of reducing pain, the incidents of opioid over-sedation and adverse drug events more than doubled. In addition, research shows that addiction to opioids can form within days, and as many as one in four people receiving long-term opioid treatments go on to struggle with opioid addiction.

Changes to Pain Management Strategies

By 2016, increasing concerns about opioid prescribing patterns led the American Medical Association to recommend that pain be removed as the fifth vital sign. The Physicians for Responsible Opioid Prescribing (PROP) formally requested that TJC re-evaluate their pain management standards, emphasizing, “pain is a symptom, not a vital sign.”

Also in 2016, the American Society of Anesthesiologists (ASA) encouraged CMS to remove specific patient survey questions regarding nurses’ and doctors’ contribution to pain management, stating that these questions impacted opioid administration patterns. ASA recommended replacement questions that reflected a more comprehensive approach to pain management, such as:

• Acknowledgement of the patients’ goals for their pain.
• Improving the patient’s functioning (i.e., tangible improvements to quality of life).
• Decreasing the period of time before the patient could return to normal activities.
• Whether alternative pain-management methods were offered (i.e., multimodal pain care).

Is There Consensus About Whether Pain Is a Vital Sign?

For two decades, several influential organizations encouraged healthcare providers to treat pain as a vital sign. The campaigns and legislation involved have since been re-evaluated and revised. However, they’ve had lingering effects in healthcare. So far, there’s no consensus on the issue. Different healthcare facilities may have differing protocols in place.

The advocates for removing pain from the group of vital signs argue that the approach led to ineffective, and sometimes harmful, interventions. A more comprehensive strategy for pain management may contribute to better patient outcomes. Critics of the revisions argue that by failing to treat pain level as a vital marker of the patient’s health, clinicians are evading the issue and pain will go untreated.

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The decision to stop considering pain as the fifth vital sign was influenced by political, cultural, and economic factors, and there may be more changes to come. We’re here to help you stay up-to-date with healthcare guides and resources to keep your facility on the leading edge.