Hospital Without Pain: Guidelines for Implementing Pain as the 5th Vital Sign (2023)


In the realm of healthcare, the responsibility and commitment to control pain and alleviate suffering rest squarely on the shoulders of healthcare professionals. Unfortunately, due to various factors such as a lack of knowledge about effective doses, duration of analgesic action, available analgesic techniques, and concerns about respiratory depression and addiction, pain is frequently undertreated in hospital settings.

Patients with cancer often face mortality while enduring moderate to severe pain. The prevalence of cancer pain ranges from 20% to 50% at diagnosis and increases to 70% to 90% in advanced stages. Inadequate postoperative pain relief remains a persistent problem, with studies revealing that even when analgesics are prescribed, a significant portion of patients still experiences pain.

The Imperative of Pain Control

Effective pain management is crucial for comprehensive patient care. As the quality of healthcare services comes under scrutiny, the focus on improving the quality of assistance to patients suffering from pain in hospital institutions has gained prominence. Quality indicators and measures, including pain assessment and management, have been developed to enhance the overall patient experience.

Recognizing the significance of pain management, the Joint Commission Accreditation Healthcare Organization (JCAHO), the leading accrediting agency in the United States, emphasizes the need for pain management in the hospital accreditation process.

Pain as the 5th Vital Sign

The concept of pain as the 5th vital sign was introduced in 1996 by James Campbell, President of the American Pain Society. Campbell's objective was to raise awareness among healthcare professionals about the importance of treating pain with the same diligence as other vital signs. Integrating pain assessment with traditional vital signs ensures immediate intervention and subsequent reevaluations.

To implement pain as the 5th vital sign effectively, hospitals should:

  • Develop a plan for implementation, assigning a dedicated team member for coordination.
  • Establish an action plan with timelines and designate responsibilities for implementation across all units.
  • Define the assessment record, intervention, and reevaluation sheet.
  • Choose the assessment instrument, such as the Visual Analog Scale (VAS).
  • Set norms and procedures for pain assessment and reevaluation.
  • Educate healthcare teams on pain assessment components, VAS application, proper recording, and reevaluation.
  • Develop an education plan for patients and their families on pain assessment and management.

Evaluating Pain

Pain, as defined by the International Association for the Study of Pain (IASP), is an unpleasant sensory and emotional experience associated with actual or potential tissue damage. Due to its subjective nature, McCaffery and Beebe emphasize that pain is what the individual experiencing it says it is.

The goals of pain assessment are to identify its etiology and understand the sensory, affective, behavioral, and cognitive aspects to propose and implement effective management. Unfortunately, studies show that postoperative pain is often underestimated by nurses.

Frequency and Recording of Pain Assessment

The frequency of pain assessment varies based on the clinical scenario. For inpatients, pain should be assessed at admission and subsequently according to the institution's routine and patient conditions. Standardizing the recording of assessments is crucial in establishing pain as the 5th vital sign. Documentation can be done on paper or electronically, showcasing pain intensity at assessment, the adopted intervention, and the reevaluation intensity.


Integrating pain assessment as the 5th vital sign into clinical practice requires a dynamic and multidisciplinary approach. Constant evaluations, continuous education, and adherence to total quality principles are essential. The physical and emotional well-being derived from pain relief underscores the need for healthcare professionals to exhibit technical and scientific competence in this field, ensuring patient rights remain at the forefront.

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Author: Foster Heidenreich CPA

Last Updated: 27/12/2023

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