Gentili, M., Clerico, M., Spizzichino, M., & Fanelli, G. (2016). Use of a checklist to improve pain control in hospitalized cancer patients: The 38Checkpain project. Future Oncology, 12, 199–205. 

To evaluate whether use of a checklist dedicated to pain management-related practices would improve pain control in inpatient settings

A checklist (38Checkpain) was developed by a group of patient management experts identifying practices related to pain management outlined in Italian law. The checklist consisted of seven items to remind practitioners of correct steps for assessment, monitoring, management, and treatment of pain. Healthcare centers participating in the program collected information on these aspects of pain management, adverse of effects, and episodes of breakthrough pain for all patients hospitalized that day on the unit for seven days. After, healthcare centers were randomized to use the checklist or to continue current practice without use of the checklist. Checklist items were measuring intensity of pain, checking if pain was 3 or less, modifying therapy if pain intensity was greater than 3, assessing the presence of adverse events with pain treatment, setting a specific therapy of adverse event management, checking for presence of factors that increase acute pain, and setting a specific therapy for treatment of factors that cause acute pain. The checklist was applied in patients with pain twice daily by providers. Data were collected for 21 days.

• N = 92 organizations, 895 patients   
• AGE: Not provided
• MALES: Not provided, FEMALES: Not provided
• KEY DISEASE CHARACTERISTICS: Not provided
• OTHER KEY SAMPLE CHARACTERISTICS: Not provided

• SITE: Multi-site   
• SETTING TYPE: Outpatient    
• LOCATION: Italy

• Prospective, randomized cohort

• 1–10 numeric pain rating scale 
• Proportion of patients with controlled pain, defined as intensity of 3 or less on numeric scale
• Incidence of adverse events
• Number and severity of breakthrough pain episodes

Mean pain intensity declined in the checklist group over the study period from 3.8–2.7. Mean pain intensity did not decline steadily in the no checklist group and overall was consistently higher. The proportion of patients with effective control of pain increased from 20.1% to 67.6% in the checklist group. In the no checklist group, control of pain increased by 13.8%. The incidence of breakthrough pain episodes decreased by 21.4% in the checklist group but increased by 6.6% in the other group. Compliance with checklist use was reported as at least once daily.

The use of a checklist to remind healthcare providers to make specific assessments and intervention plans for patients with pain appeared helpful in improving overall pain-related patient outcomes.

• Risk of bias (no blinding)
• Risk of bias (sample characteristics)
• Measurement validity/reliability questionable
• Very little information to describe the patients is provided. 
• No statistical analysis was done. 
• The control group was about half the number of sites as the checklist cohort.
• Patients of whom data were collected from week to week were different patients, so it is unclear if outcomes differed based on the intervention examined here or on other patient conditions.

This study has multiple limitations; however, it does suggest that at least daily use of a checklist reminder for assessment and intervention practices for patients with pain may improve overall pain management and related patient outcomes. Checklists have been used in multiple ways in health care and may be an effective tool in reminding practices to improve various types of patient outcomes.