The rapid increase in confi rmed cases of COVID-19 is placing a heavy burden on medical care systems. A case study of a tertiary referral medical center in central Taiwan was performed to present models for pain care for hospitalized patients with COVID-19.

From August to December 2021, 32 adult hospitalized patients with COVID-19 were included in the study. The characteristics of pain experienced by patients and pain management were examined. Non-intubated patients completed the numeric rating scale. Regarding severely ill patients, the critical care pain observation tool (CPOT) was applied to assess their pain. The clinical decision support system, called 3324 system was implemented to improve pain management.

Thirty-two adult patients (15 men; 17 women) were included in the study, and 9 of them (28.1%) were intubated and required intensive care unit admission. Eleven patients (34.4%) experienced moderate pain or severe pain. The main causes of pain were headache, sore throat, and pain at upper trunk. Regarding severely ill patients, 6 patients had a CPOT score of ≥ 2. The number of cases in the present hospital’s 3324 system between May and July 2021 was not greater than the number of cases over the same period in 2020.

At our hospital, nearly half of the hospitalized patients with COVID-19 experienced moderate to severe pain. Hence, the pain issue of confi rmed cases of COVID-19 must be taken seriously. Although the pandemic caused changes in medical care, the hospital has been able to maintain its quality of care through the implementation of various pain monitoring and response measures. The findings demonstrate that promoting clinical decision support system and specialized case management can improve the quality of care.

COVID-19, pain management, SARS-CoV-2

The SARS-CoV-2 virus has spread rapidly around the world since the end of 2019, exerting far-reaching effects on the economy, transportation, and life. Medical systems bore the brunt of these impacts. The rapid increase in confi rmed cases is placing a heavy burden on medical care systems. The contagious nature of the SARS-CoV-2 virus and the ratio of severe cases have completely changed past care models.

The goal of Taichung Veterans General Hospital to be established as a pain-free hospital, which involves the implementation of various pain man agement measures, has not been changed by the COVID-19 pandemic. Herein, a case study of a tertiary referral medical center in central Taiwan was performed to present models for caring for patients with COVID-19. The characteristics of pain experienced by patients with COVID-19 were determined. Furthermore, the means by which telemedicine can be employed to improve pain assessment and provide immediate treatment were explored.

This study was conducted from August to December 2021 at Taichung Veterans General Hospital, a teaching hospital and tertiary referral medical center in central Taiwan with approximately 1,500 beds. Pain management of hospitalized patients with COVID-19 was examined. The institutional review board of Taichung Veterans General Hospital approved the study protocol (Protocol no. CE21458B).

Patients diagnosed with COVID-19 in 2021 and hospitalized in general wards or intensive care units (ICUs) of the hospital were included. Patients younger than 20 years of age or patients without a complete electronic medical record were excluded.

In 2021, Taichung Veterans General Hospital treated 37 patients with COVID-19, and 5 patients under 20 years of age were excluded. Thirty-two adult patients (15 men; 17 women) were included in the study, the mean age was 55.4 ± 15.8 years, and their comorbidities were also surveyed (Table 1). We classified 10 patients as critical illness according to the COVID-19 treatment guidelines [1], and 9 of them (28.1%) were intubated and required ICU admission. The level of d-dimer and thromboembolic events during the hospitalization of patients were also obtained (Table 2). The genome sequence of the patients was not analyzed, but based on genomic epidemiology in Taiwan in 2021, the majority of cases were infected with SARS-CoV-2 alpha variants [2].

Table 1. Participant Characteristics

Table 2. Clinical Feature of the Patients

Non-intubated patients completed the numeric rating scale for pain assessment. Their pain levels were classified as no pain (0), mild pain (1–3), moderate pain (4–6), or severe pain (7–10). Maximum pain score during hospitalization of each patient was recorded. Eleven patients (34.4%) experienced moderate pain (31.3%) or severe pain (3.1%) (Table 3). The main cause of the pain was temporal, vertex, or occipital headache. Overall, 11 patients (34.4%) experienced headache, 10 patients (31.3%) experienced a sore throat, and 9 patients (28.1%) experienced pain at upper trunk (Table 4).

Regarding the severely ill patients, the critical care pain observation tool (CPOT) was applied to assess their pain. Six patients had a CPOT score of ≥ 2, indicating that they were in severe pain.

Table 3. Pain Severity

Table 4. The Location of Pain

The hospital used multiple measures to improve the quality of pain management it provided and to work toward its goal of becoming a pain-free hospital [3]. These included the use of the clinical decision support system, comprehensive pain assessment and treatment implemented by nurses during each shift, the establishment of the patient-controlled analgesia team, and the appointment of case managers.

Nurses conduct at least two pain assessments for each patient during their 8-hour shifts. If special circumstances occur, they increase the frequency of assessment, treat and examine patients according to medical orders, and review the effects of treatment. The frequency and efficiency of pain assessments were not less than or inferior to those provided to regular patients because patients with COVID-19 were isolated from other patients.

Taichung Veterans General Hospital implements the 3324 system. Connected with the medical record system, the 3324 system identifies patients with a pain score of > 3 more than three times over the past 24 hours. Pain management team assists physicians in conducting pain assessment and providing treatment for patients in whom pain control is ineffective so that pain control can be optimized.

A large number of COVID-19 cases and COVID-19 hospitalizations began emerging in Taiwan in May 2021. However, the number of cases in the present hospital’s 3324 system between May and July 2021 was not greater than the number of cases over the same period in 2020. This demonstrates that pain management provided to patients at Taichung Veterans General Hospital was not affected by the pandemic; the hospital maintained the same level of care provided in the past. Furthermore, confirmed cases were not included in the 3324 system, and it shows that they received proper pain management.

Several studies reveal that COVID-19 is associated with a hypercoagulopathy state owing to the dysregulation of inflammation and coagulation.

Hypercoagulability induces venous or arterial thrombosis that causes deep vein thrombosis and multiple thrombi in vessels of the lungs, kidneys, and other organs [4]. Symptoms of deep vein thrombosis in the leg are throbbing or cramping pain, and the severity of pain may gradually increase owing to prolonged ischemia time. In Table 2, 11 patients (34.4%) can be seen to have a thromboembolic event or received anticoagulant owing to the elevated d-dimer level during hospitalization. However, these patients did not have a higher pain score or obvious extremity pain.

Since the pandemic began, people have been more reluctant to seek medical attention, but demand for outpatient care remained steady. Therefore, some hospitals established telemedicine programs, in which phone or video calls are used to provide diagnoses and treatments. This unique medical model can reduce the risk of medical personnel contracting diseases, as well as prevent cluster infection on transportation systems or at hospitals. However, telemedicine can increase the difficulty of diagnosis. Some departments of the hospital developed specific diagnostic methods for use in telemedicine. For example, the orthopedic department assessed patient pain on the basis of a comprehensive framework for musculoskeletal and neurological examination [5]. In accordance with guidelines, telemedicine should be considered for application to the management of chronic pain in patients during the COVID-19 pandemic. The Medical Council of India passed the Telemedicine Practice Guidelines to establish the legality of telemedicine consultation and prescription [6].

In addition to developing telemedicine programs for outpatient care, protecting hospitalized patients and medical personnel from infection is a crucial consideration. Medical personnel must follow complex procedures concerning the donning and doffing of personal protective equipment, which must be worn when entering or exiting isolation wards. During this process, medical personnel is at higher risk of contracting COVID-19. The hospital established temporary specialized wards to accommodate a potentially large number of severe COVID-19 cases. In these wards, information on patients’ vital signs is delivered to the central nursing station in real- time. Further more, the hospital installed real-time audio and video systems enabling physicians to assess and treat the patients without delay. The risk of disease spread was greatly reduced because medical personnel did not have to contact patients frequently. This model can be applied to the monitoring and adjustment of pain relief administered to severely ill patients.

Because the present hospital is located in central Taiwan, it has treated fewer hospitalized patients with COVID-19 than its counterpart in northern Taiwan; the pandemic has had a smaller effect on its operations. Nationwide or worldwide data should be collected to compare the practices of medical institutions employing similar pain management models, as well as to determine whether hospitals were able to maintain their level of care during severe periods of the ongoing pandemic.

Analyses can be conducted for patients in hospitals with reduced medical capacities, such as hospitals that suspended general surgeries and only completed emergency or time-sensitive surgeries. Studies can investigate whether the pain characteristics, pain frequency, and demand for pain relief of such patients differed before and after the pandemic began.

We do not evaluate the condition of pre-existing pain among our patients. Some patients have pain related symptoms before COVID-19 infection, and the symptoms may worsen with intensive care support during hospitalization [7].

Furthermore, the long-term complications of COVID infection have not been studied widely, such as SARS-CoV2 related neuropathic pain, and these conditions can be theoretically associated with persistent chronic pain [8]. In the future, further studies could be conducted to investigate the prevalence of chronic pain among patients with COVID-19.

At Taichung Veterans General Hospital, 40% of all hospitalized patients with COVID-19 experienced moderate-to-severe pain, and 60% of all severe COVID-19 cases experienced moderate-to-severe pain. These results indicate that the pain of patients with this disease must be taken seriously. The 3324 system has been developed and applied to monitor pain patients since 2018 and produced excellent results. Although the pandemic caused changes in medical care, including increases in the workload of medical personnel, the hospital has been able to maintain its quality of care through the implementation of diverse pain monitoring and response measures. The findings demonstrate that promoting monitoring systems and specialized case management can improve the quality of care. Furthermore, telemedicine programs should be established in outpatient clinics and applied to the treatment of patients in isolation wards. Telemedicine enables real-time communication between patients and physicians, reduces treatment delays attributable to isolation measures, and substantially diminishes the risk of infection caused by close contact between patients and medical personnel. Even if the pandemic becomes more severe in the future, Taichung Veterans General Hospital will strive to provide its patients with consistent pain management through the use of optimized monitoring systems and care models.