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Development and Implementation of a Pain Management Program
DECEMBER 1996, VOL 64,NO 6 Campese
Development and Implementation of a Pain Management Program
I
n 1992, the Agency for Health Care Policy and Research (AHCPR) published guidelines for the management of acute pain. The guidelines included four major goals. These goals were to: reduce the incidence and severity of patients’ acute postoperative and posttraumatic pain; educate patients about the need to communicate unrelieved pain so they can receive prompt evahation and effective treatment; enhance patient comfort and satisfaction; and contribute to fewer postoperative complications and, in some cases, shorter stays after surgical procedures.’ In addition, supporting literature stated that routine orders for intramuscular injections “as needed” leave more than half of postoperative patients with
unrelieved pain due to undermedication.* Based on all this information, perioperative nurses in the outpatient surgical center (OSC) and the main postanesthesia care unit (PACU) at St Mary’s Health Care System, In@ (St Mary’s), in Athens, Ga, identified pain management as an important focus of our quality improvement program. DEVELOPMENT OF THE PAIN MANAGEMENT PROGRAM
Since the fall of 1992, one of St Mary’s surgical nursing units had been piloting the use of a pain scale, which had been preapproved by the hospital’s surgeons before implementation. This five-point scale allowed patients to self-report their levels of postoperative pain. The surgical unit nurses assured patients on admission to the unit, both verbally and in a letter, that nurses would be vigilant in medicating patients if their levels of pain reached three A B S T R A C T Perioperative nurses at St Mary’s Health Care System, Inc” on the five-point scale (Figure 1). The quality improvement (St Mary‘s), in Athens, Ga, recognized that some of their postoperative patients did not have an acceptable level of pain control. Based coordinator for surgical services on the Agency for Health Care Policy and Research acute pain man- (who represents both the main agement guidelines, they developed and implemented a pain man- surgical services and OSC) and agement program. This quality improvement program led to a multi- the main PACU head nurse met disciplinary effort to maintain each postoperative patient‘s pain at a with the surgical unit head nurse level acceptable to that individual. Using a pain level scale, patients to discuss extending the use of are taught to self-report their levels of pain so that medication can the pain scale to all surgical be administered appropriately and on a timely basis. A quality patients. Having all surgical improvement team is studying compiled data and anticipates mak- patients use the pain scale would ing recommendations about best practices with regard to medication help all perioperative nurses meet utilization. In September 1995, St Mary‘s underwent a mock Joint the goals of the AHCPR guideCommission on Accreditation of Healthcare Organizations survey. lines and provide for consistent assessThe surveyors were impressed with the quality and content of the ment and continuity of care pain management program. Suggestions for other facilities that wish throughout patients’ surgical to establish pain management programs are included. AORN J 64 (Dec 1996) 931-940. courses; CLAUDIA CAMPESE.
931 AORN JOURNAL
HN
DECEMBER 1996, VOL 64,NO 6 Campese 9
I no pain
I
I
slight or mild pain
I
moderate pain
severe pain
Figure 1 Nonverbal flve-polnt paln level scale. (Figures I onu 3 used wlrh jmnn/ss/onor P H COW,
I
worst pain MD, MPH, Commun/iy HOSP/CO
CoreNltcrs HeoNhwre, Omnge, CoIM)
be compatible with all methods of pain control; provide a method to reevaluate pain after intervention; provide a means of assessing postdischarge pain at the time of the follow-up telephone call: be of value in the development of critical pathways; and extend the scale’s use to the great majority of patients, including children over the age of four years.3 Program proposal. These nursing leaders brought the proposal to expand the use of the pain scale to the nursing quality improvement council (NQIC) for discussion. The council, chaired by the nursing quality improvement coordinator, is composed of quality improvement representatives and/or the head nurse from each nursing unit in the hospital. Council members were unanimous in their support for the proposal. In addition to subscribing to the AHCPR guidelines, NQIC members believed that the development of a pain management program would provide the nursing department an opportunity to implement the Joint Commission on Accreditation of Healthcare Organization’s (JCAHO’s) Agenda for Change,“ which calls for the focus of health care to improve performance as measured by outcomes. Provisions for patient rights, patient education, and patient satisfaction are included in the new JCAHO guidelines. Within this framework, JCAHO also specified that the care provided meet certain dimensions of performance. Those dimensions are appropriateness, effectiveness, timeliness, efficacy, efficiency, availability, safety, continuity, and respect and ~ a r i n g . ~ The NQIC members wanted to incorporate these dimensions of performance into the pain management program, and the vice president of nursing
approved the decision. The director of nursing assisted the nursing council members in identifying the broader implications of a pain management program. Published AHCPR clinical practice guidelines on managing cancer pain made it apparent that patients with chronic pain could experience the same benefits from a pain management program as patients with acute pain. The NQIC members believed the program would be successful and decided to include medical as well as surgical patients. Implementation timetable. We developed a timetable for program implementation and decided that surgical patients and emergency department (ED) patients would initiate the program. After three months, we would integrate the medical patients. As the surgery unit nurses had begun their pilot pain management program more than one year earlier, NQIC members contacted each surgeon by mail to inform him or her of the committee’s intentions to expand the program and to elicit the surgeons’ suggestions and approval. We sent each surgeon a copy of the cover letter and the information we planned to distribute to patients. We received no negative responses and incorporated some suggestions from the surgeons into our patient literature. POUCY AND PROCWlRI
Our next step was to develop a policy and procedure for our pain management program. Quality improvement representatives from the specialty units believed that the procedure for informing patients of the pain management program would be very different for specialty and nonspecialty units. To determine if this assumption were valid, we constructed a flow chart (Figure 2) of the different avenues through which patients are admitted to the hospital. We also charted the steps in each of those avenues. We discovered that the process is nearly identical regardless of the point of admission. The procedure, therefore, could be developed under the umbrella of nursing. The director of nursing indicated that any differences in procedure needed by individual nursing units could be addressed as a unit addendum. 932
AORN JOURNAL
DECEMBER 1996, VOL 64, NO 6 CaniprsP
Figure 2 PAIN CONTROL TEACHING, AVENUES OF ADMISSION
After much discussion and literature review, NQIC members formulated the policy. We wanted to ensure that each patient would have effective pain control, regardless of his or her diagnosis, age, and/or ability to use the pain level scale. With consultation from a clinical nurse specialist in pain management at Emory University Hospital in Atlanta, we formulated the following policy: Each patient entering St Mary’s Hospital or Outpatient Surgical Center will have his or her pain managed in such a way that it remains at or helow a Iei,el three on the St Mary’s Hospital Pain Intensity Scale, or is at
a level acceptable to the individual.6 As we learned more about pain management, the members of the nursing council realized that there was potential to broaden the scope of our program. Members from both the surgical services quality improvement council and the nursing services quality improvement council attended a pain management seminar presented by three clinical nurse specialists from the Emory University Hospital pain clinic. The presenters discussed medications, types of pain, and nonpharmacological interventions (eg, relaxation techniques, music therapy, distraction, imagery). We incorporated much of this
934 AORN JOURNAL
DECEMBER 1996, VOL 64,NO 6 Campese 9
8
(Adapted with permission of St Mary’s Health Care System, In@, Athens, Ga)
information into an inservice program that we developed for staff members at St Mary’s.
coping skills, vital signs, medical or surgical history (past and present), STAR EDUCATION socioeconomic status, The surgical services quality improvement coorcultural background, dinator conducted the inservice program for each nursgender, and ing unit and videotaped the program for staff members intellectual abilities. who were unable to attend. One of the main points she A nurse’s own experience with pain and patients in stressed during the inservice program was that “the pain also influences his or her assessment of single most reliable indicator of the existence and patients’ pain. intensity of acute pain-and any resultant affective Patient coping mechanisms. Patients exhibit a discomfort or distress-is the patient’s ~elf-report.”~wide range of coping mechanisms when dealing with Nursing assessments of a patient’s pain level are influ- pain. Some talk and laugh, some lie perfectly still, enced by a variety of factors, including the patient’s and others writhe and moan. The self-reporting pain 935 AORN JOURNAL
DECEMBER 1996, VOL 64,NO 6 Campese 9
scale allows each patient to identify his or her own level of pain regardless of how the nurse is influenced by other factors. Medications. During the inservice education program, nurses described situations in which they were unsure when patients needed analgesics. The scenario of a patient who had been sleeping soundly, then woke up complaining of severe pain was familiar to many of the nurses. They did not think pain medication was really necessary in such situations, because they could not understand how a patient in pain could sleep. The inservice program alerted the nurses to the fact that the commonly ordered combination of meperidine hydrochloride and promethazine hydrochloride may not be the most effective treatment for postoperative pain. Meperidine hydrochloride commonly is underdosed and administered too infrequently,Eand promethazine hydrochloride causes sedation, thus creating the appearance of pain relief. The nurses realized that although they cannot change the medication a physician prescribes, they can-indeed, they have an obligation to-call the physician any time a patient does not achieve an acceptable level of pain control. Ideally, the physician would then order a higher dosage of the medication or prescribe a different analgesic. The surgical services quality improvement coordinator encouraged the nurses to make the commitment to their patients to provide an acceptable level of pain control. During the inservice program, she also instructed the nurses to know how and when to teach the use of the pain level scale, how to assess the pain that patients experience (eg, location, quality, onset, duration), and the proper method for documentation. Some of the nurses practiced relaxation breathing techniques during the inservice program, and the surgical services quality improvement coordinator encouraged them to help their patients use relaxation breathing, music therapy, and other comfort measures to relieve postoperative pain. She reinforced the concepts taught during the inservice program by making available to each unit a videotape of the education program; copies of the patient letter detailing the pain management program and use of the pain level scale; and the AHCPR clinical practice guidelines, quick reference guidelines, and patient guides for pain management.
mNALpRIpAnATmN
By December 1994, we had presented the inservice education program for all nursing units at St Mary’s. To remind staff members of the Jan 1, 1995, pain management program implementation date, we hung posters and sent memoranda to all nursing units. In addition, some nursing units laminated enlarged copies of the pain level scale and hung them at the nursing stations and in patient rooms. The pediatric unit head nurse revised the pain level scale to make it easier for children to recognize the various levels of comfort. She also revised the patient letter to explain the use of the scale in age-appropriate terms. According to the AHCPR guidelines, children ages four years and older are able to use the scale. For younger children and infants, we planned to work with the parents and use their assessments of children’s pain (eg, children’s behavior) to evaluate the levels of pain the children were experiencing. IMPUMINTAWON
We supplied each nursing unit with copies of the adult and pediatric versions of the patient letter. When a patient was admitted to St Mary’s, a nurse would give a copy of the letter and pain level scale to the patient during the initial assessment and teaching period. We believed that providing each patient with the letter represented a written contract that stated we intended to do our utmost to help the patient achieve postoperative pain control. The NQIC members and the head nurses were excited about the new program, but many of the staff nurses expressed doubtful opinions such as “It’s one more piece of paper” or “One more thing to remember to do and to chart.” The NQIC members encouraged the staff nurses to express their thoughts and ideas about the program and reminded them that the first three months were a trial period and that program revisions might be necessary. Based on their experiences with the patients, the staff nurses would be the first to recognize the potential areas for revision. As with many new programs, initial compliance by the nursing staff members began slowly. As each nurse gained experience with teaching the pain management program and helping patients use the pain level scale, however, we began hearing success stories from both nurses and patients. One nurse related the story of a pediatric patient who was recovering from abdominal surgery. The child emerged from the bathroom pointing to the big
937 AORN JOURNAL
DECEMBER 1996, VOL 64,NO 6 Compese
symptoms required surgery. We do not perform cardiac surgery at St Mary’s; therefore, the admission of a patient for cardiac surgery would be a rare occurrence. The director of nursing supported the decision to use the two scales and asked that docuPostanesthesia care unit modifications. mentation be adapted to encompass the two scales. Although the scale was a good tool for some PACU Nurses now chart pain levels with a split number to patients, the self-report was inappropriate for some indicate which scale they are using. The first numpatients. After much discussion, the PACU nurses ber represents the patient’s level of pain. The second decided to medicate their patients based on a nursing number represents which scale is being used. For assessment of nonverbal behaviors (Table 1) until example, a pain level of four on the five-point scale is documented 415; a level of five on the 10-point scale is documented 5/10. Table 1 Pilot approved. The remainNONVERBAL PAIN SCALE der of the three-month trial periCode Word scale Nonverbal behavlors od passed fairly smoothly. On April 1, 1995, after approval by 1 No pain Relaxed, calm expression the medical staff members, all St 2 Slight or mild pain Stressed, tense expression Mary’s patients were added to the
smile on his own face. The nurse was puzzled at first but the child’s mother explained, “He’s showing you his smile, like the one on the scale.” Another PACU nurse told of her patient who waved four fingers to indicate his level of pain.
3
Moderate pain
Guarded movement, grimacing
pain management program. We were encouraged to 4 Severe pain Moaning, restless note AOFW’s “Perioperative nurse 5 Worst pain Crying out, increased intensity translation of the AHCPR clinical practice guidelines,” which was of above behaviors published in the 1995 edition of A standards and Re (Adapted with permission from St Mary‘s Healih Care %stern, In@, Ahens, Ga) mended practice^.^ We believe our program aligns closely with patients were alert enough to self-report their pain. AORN’s translation of the AHCPR guidelines. If possible, PACU nurses elicit patients’ self-reported levels of pain before transferring them to postop- P R - ~ EXPANerative nursing units. This initial assessment estabWe had informed the ancillary quality improvelishes a baseline for the nursing unit staff members ment council (AQIC), a multidisciplinary committee to use when evaluating patients’ postoperative pain consisting of representatives from every area of the management. hospital system, of our intent to focus on pain manageEmergency department modifications. ED ment. As our program evolved, we kept AQIC memnurses identified another issue concerning the use of bers apprised of its progress. Eventually, the AQIC the five-point pain scale. The cardiologists serving adopted pain management as a systemwide focus. our hospital requested that their patients use a 10Concurrent with the development and implepoint pain scale when evaluating their chest pain. mentation of the pain management program, the The cardiologists believe that the 10-point scale director of St Mary’s quality improvement center, gives a more accurate picture of pain and the control who was also the AQIC chairman, formed a quality achieved. team specifically to address pain management. The NQIC discussed this issue in depth at ‘its The quality team for pain management initially had February 1995 meeting. Proponents of each scale representatives from nursing, surgical services, pharvoiced opinions, and the decision was made to con- macy, and continuous quality improvement departtinue using the five-point scale for all patients ments. Representatives from the long-term care except those referred for cardiac problems. We facility, rehabilitation, hospice, and home health understood that the use of two scales might cause joined shortly thereafter. some confusion, especially if a patient with cardiac The quality team identified the need to monitor 938 AORN JOURNAL
DECEMBER 1996, VOL 64,NO 6 Campese 8
Figure 3 Nonverbal 1 0-point pain level scale. the pain management program by focusing on medication utilization evaluation. Those patients who did not have their pain controlled at a level three or less on the five-point scale would be identified and their medical records reviewed using criteria approved by the medical staff pharmacy committee. We decided to study patients on the surgical nursing unit that had been using the pain scale for two years. We also included PACU patients who had extended stays in the PACU for pain control. The quality team was unable to draw conclusions based on the initial data collected about patients with pain levels of three or above. The team decided that the patient population studied was too broad and lacked a comparable control group and information was missing (eg, If a patient did not achieve pain control, did a nurse seek a change in medication? Was the pain medication given on a timely basis?). To more clearly focus the study, quality team members agreed on two statements. Patients having total knee replacement procedures experience the greatest amount of postoperative pain. Patients who use a patient-controlled analgesia (PCA) pump achieve the best pain control. Using these statements as a baseline, the quality team members are planning a retrospective review of medical records of all patients who have undergone total knee replacement to compare medication cost and efficacy. The quality team also selected these patients for study because the hospital performs a sufficient number of the procedures each year and patient length of stay for this procedure is long enough to generate useful information. Data gathered will include route and dosage of pain medication, type of anesthesia administered, total morphine equivalency,
length of stay, use of PCA, and adjunctive administration of nonsteroidal antiinflammatory medications. EVALUATION
Our program is still in its infancy, and it will be some time before we have enough data to draw specific conclusions. Hospitalwide, we are measuring the program’s success by using the results of an independent firm’s surveys of inpatient and outpatient satisfaction with many aspects of the hospital’s functions. The consulting fm compares our results with those from other hospitals of the same size and type. Our goal is to maintain a raw patient satisfaction score above 90 for the question “How well was pain controlled?” For the time period of Feb 1, 1995, through May 1, 1995, our raw score was 92.1, placing St Mary’s in the 99th percentile for this question when compared with 360 similar hospitals nationwide. Concurrently, NQIC members reviewed documentation of patient teaching related to pain management and noted that compliance increased as the program gained acceptance. The NQIC members also reviewed medical records for documentation of patients’ levels of pain using either the five-point or 10-point pain scale and noted that compliance increased over time. The NQIC members, however, encountered some difficulty interpreting the documentation due to the use of two pain scales. To provide for consistency in documentation, the NQIC voted to use only the 10-point scale (Figure 3) and instituted this change in early 1996. We revised the policy, procedure, and nonverbal behavioral scale to reflect use of the 10-point scale. Our 1996 assessment of the pain management program will use the independent survey firm results, as well as the review of documentation in patients’ medical records. All hospital nursing units
939 AORN JOURNAL
DECEMBER 1996, VOL 64, NO 6 Campese 9
are using the same study criteria now that the program is implemented. CONCLUSIONS AND RECOMMENDATIONS
In September 1995, St Mary’s underwent a mock JCAHO survey. The surveyors were impressed with the quality and content of the pain management program and stated that we should share our information with other facilities. The surveyors suggested that we offer more music therapy as part of the pain management program. One way to include music therapy is to educate patients on the benefits of music and provide audiotapes for patients to use. The pain management program is now recognized by hospital staff members as an important aspect of quality patient care. Quality improvement committee members will update staff members on the progress of the program, and we also will provide progress reports via storyboards placed throughout the hospital. The NQIC and the quality team members hope to draw specific conclusions about the quality of pain control patients achieve to identify best practices. The knowledge gained also will be used in developing critical pathways. Our ultimate goal is to provide all patients exceptional care and optimal outcomes. We believe that this information about our pain management program’s development can help other facilities that wish to develop pain management programs of their own. Questions to consider when contemplating the establishment of a pain manageNOTES 1. Agency for Health Care Policy and Research, Management of Cancer Pain, Clinical Practice Guideline (Rockville, Md: US Department of Health and Human Services, 1994). 2. Agency for Health Care Policy and Research, Acute Pain Management in Infants, Children, and Adolescents: Operative and Medical Procedures, Quick Reference Guide for Clinicians (Rockville, Md US Department of Health and Human Services, 1992). 3. J DiGregorio, Handbook of Pain Management, third ed (West Chester, Pa: Medical Surveillance, 1991). 4. Joint Commission on Accreditation of Healthcare Organizations,
ment program follow. What should the program accomplish specifically? Are physicians supportive? What resources will be necessary? What department or team will be responsible for developing the program? Which pain level or visual analog scale best meets the needs of patients seen at the facility? How will information about the program be dispersed to staff members and patients? What data will be collected, and how will they be collected? We encourage other health care facilities to recognize pain control as an important aspect of care. Adequate pain control facilitates patient comfort, promotes postoperative healing, and increases patient satisfaction. Through collaborative efforts, health care professionals can care effectively for patients who are experiencing pain. A Claudia Campese,RN, BS, CNOR, is an OR staff nurse at St Mary’s Health Care System, Inca, Athens, Ga. She was the quality improvement coordinator for surgical services at St Mary’s at the time this article was written.
The author would like to acknowledge Lorraine Spann Edwards, director of public relations, and Kymy Pruitt, RN, BSN, MEd, project manager, clinical process redesign, St Mary’s Health Care System, Inca, Athens, Ga,for their assistance with this article.
“Agenda for change: Q & A,” Perspectives 12 (JanuaryPebruary 1992). 5. “Hospital uses federal guidelines to create its policy on pain,” Hospital Peer Review 19 (September 1994) 140-141. 6. St Maiy’s Health Care System, In@, Pain Management Policy (Athens, Ga: St Mary’s Health Care System, In@, 1995). 7. M McCaffery, A Bebee, Pain: Clinical Manual for Nursing Practice (St Louis: Mosby, 1989). 8. B Reed, J Alexander, J Rice, “Management of the patient in pain: Nursing implications,” seminar presented at Habersham County Medical Center, Demorest, Ga, November 1994. 9. K Schmidt et al, “Implementa940 AORN JOURNAL
tion of the AHCPR pain guidelines for children,” Journal of Nursing Care Quality 8 (April 1994) 68-74; “Perioperative nurse translation of the AHCPR clinical practice guidelines,” in AORN Standards and Recommended Practices (Denver: Association of Operating Room Nurses, Inc, 1995). SUGGESTED READING Guyton-Simmons, J; Ehrmin, J T. “Problem solving in pain management by expert intensive care nurses.” Critical Care Nurse 14 (October 1994) 37-44. Tieman, P. “Independent nursing interventions: Relaxation and guided imagery in critical care.” Critical Care Nurse 14 (October 1994 ) 4751.
Development and Implementation of a Pain Management Program
I
n 1992, the Agency for Health Care Policy and Research (AHCPR) published guidelines for the management of acute pain. The guidelines included four major goals. These goals were to: reduce the incidence and severity of patients’ acute postoperative and posttraumatic pain; educate patients about the need to communicate unrelieved pain so they can receive prompt evahation and effective treatment; enhance patient comfort and satisfaction; and contribute to fewer postoperative complications and, in some cases, shorter stays after surgical procedures.’ In addition, supporting literature stated that routine orders for intramuscular injections “as needed” leave more than half of postoperative patients with
unrelieved pain due to undermedication.* Based on all this information, perioperative nurses in the outpatient surgical center (OSC) and the main postanesthesia care unit (PACU) at St Mary’s Health Care System, In@ (St Mary’s), in Athens, Ga, identified pain management as an important focus of our quality improvement program. DEVELOPMENT OF THE PAIN MANAGEMENT PROGRAM
Since the fall of 1992, one of St Mary’s surgical nursing units had been piloting the use of a pain scale, which had been preapproved by the hospital’s surgeons before implementation. This five-point scale allowed patients to self-report their levels of postoperative pain. The surgical unit nurses assured patients on admission to the unit, both verbally and in a letter, that nurses would be vigilant in medicating patients if their levels of pain reached three A B S T R A C T Perioperative nurses at St Mary’s Health Care System, Inc” on the five-point scale (Figure 1). The quality improvement (St Mary‘s), in Athens, Ga, recognized that some of their postoperative patients did not have an acceptable level of pain control. Based coordinator for surgical services on the Agency for Health Care Policy and Research acute pain man- (who represents both the main agement guidelines, they developed and implemented a pain man- surgical services and OSC) and agement program. This quality improvement program led to a multi- the main PACU head nurse met disciplinary effort to maintain each postoperative patient‘s pain at a with the surgical unit head nurse level acceptable to that individual. Using a pain level scale, patients to discuss extending the use of are taught to self-report their levels of pain so that medication can the pain scale to all surgical be administered appropriately and on a timely basis. A quality patients. Having all surgical improvement team is studying compiled data and anticipates mak- patients use the pain scale would ing recommendations about best practices with regard to medication help all perioperative nurses meet utilization. In September 1995, St Mary‘s underwent a mock Joint the goals of the AHCPR guideCommission on Accreditation of Healthcare Organizations survey. lines and provide for consistent assessThe surveyors were impressed with the quality and content of the ment and continuity of care pain management program. Suggestions for other facilities that wish throughout patients’ surgical to establish pain management programs are included. AORN J 64 (Dec 1996) 931-940. courses; CLAUDIA CAMPESE.
931 AORN JOURNAL
HN
DECEMBER 1996, VOL 64,NO 6 Campese 9
I no pain
I
I
slight or mild pain
I
moderate pain
severe pain
Figure 1 Nonverbal flve-polnt paln level scale. (Figures I onu 3 used wlrh jmnn/ss/onor P H COW,
I
worst pain MD, MPH, Commun/iy HOSP/CO
CoreNltcrs HeoNhwre, Omnge, CoIM)
be compatible with all methods of pain control; provide a method to reevaluate pain after intervention; provide a means of assessing postdischarge pain at the time of the follow-up telephone call: be of value in the development of critical pathways; and extend the scale’s use to the great majority of patients, including children over the age of four years.3 Program proposal. These nursing leaders brought the proposal to expand the use of the pain scale to the nursing quality improvement council (NQIC) for discussion. The council, chaired by the nursing quality improvement coordinator, is composed of quality improvement representatives and/or the head nurse from each nursing unit in the hospital. Council members were unanimous in their support for the proposal. In addition to subscribing to the AHCPR guidelines, NQIC members believed that the development of a pain management program would provide the nursing department an opportunity to implement the Joint Commission on Accreditation of Healthcare Organization’s (JCAHO’s) Agenda for Change,“ which calls for the focus of health care to improve performance as measured by outcomes. Provisions for patient rights, patient education, and patient satisfaction are included in the new JCAHO guidelines. Within this framework, JCAHO also specified that the care provided meet certain dimensions of performance. Those dimensions are appropriateness, effectiveness, timeliness, efficacy, efficiency, availability, safety, continuity, and respect and ~ a r i n g . ~ The NQIC members wanted to incorporate these dimensions of performance into the pain management program, and the vice president of nursing
approved the decision. The director of nursing assisted the nursing council members in identifying the broader implications of a pain management program. Published AHCPR clinical practice guidelines on managing cancer pain made it apparent that patients with chronic pain could experience the same benefits from a pain management program as patients with acute pain. The NQIC members believed the program would be successful and decided to include medical as well as surgical patients. Implementation timetable. We developed a timetable for program implementation and decided that surgical patients and emergency department (ED) patients would initiate the program. After three months, we would integrate the medical patients. As the surgery unit nurses had begun their pilot pain management program more than one year earlier, NQIC members contacted each surgeon by mail to inform him or her of the committee’s intentions to expand the program and to elicit the surgeons’ suggestions and approval. We sent each surgeon a copy of the cover letter and the information we planned to distribute to patients. We received no negative responses and incorporated some suggestions from the surgeons into our patient literature. POUCY AND PROCWlRI
Our next step was to develop a policy and procedure for our pain management program. Quality improvement representatives from the specialty units believed that the procedure for informing patients of the pain management program would be very different for specialty and nonspecialty units. To determine if this assumption were valid, we constructed a flow chart (Figure 2) of the different avenues through which patients are admitted to the hospital. We also charted the steps in each of those avenues. We discovered that the process is nearly identical regardless of the point of admission. The procedure, therefore, could be developed under the umbrella of nursing. The director of nursing indicated that any differences in procedure needed by individual nursing units could be addressed as a unit addendum. 932
AORN JOURNAL
DECEMBER 1996, VOL 64, NO 6 CaniprsP
Figure 2 PAIN CONTROL TEACHING, AVENUES OF ADMISSION
After much discussion and literature review, NQIC members formulated the policy. We wanted to ensure that each patient would have effective pain control, regardless of his or her diagnosis, age, and/or ability to use the pain level scale. With consultation from a clinical nurse specialist in pain management at Emory University Hospital in Atlanta, we formulated the following policy: Each patient entering St Mary’s Hospital or Outpatient Surgical Center will have his or her pain managed in such a way that it remains at or helow a Iei,el three on the St Mary’s Hospital Pain Intensity Scale, or is at
a level acceptable to the individual.6 As we learned more about pain management, the members of the nursing council realized that there was potential to broaden the scope of our program. Members from both the surgical services quality improvement council and the nursing services quality improvement council attended a pain management seminar presented by three clinical nurse specialists from the Emory University Hospital pain clinic. The presenters discussed medications, types of pain, and nonpharmacological interventions (eg, relaxation techniques, music therapy, distraction, imagery). We incorporated much of this
934 AORN JOURNAL
DECEMBER 1996, VOL 64,NO 6 Campese 9
8
(Adapted with permission of St Mary’s Health Care System, In@, Athens, Ga)
information into an inservice program that we developed for staff members at St Mary’s.
coping skills, vital signs, medical or surgical history (past and present), STAR EDUCATION socioeconomic status, The surgical services quality improvement coorcultural background, dinator conducted the inservice program for each nursgender, and ing unit and videotaped the program for staff members intellectual abilities. who were unable to attend. One of the main points she A nurse’s own experience with pain and patients in stressed during the inservice program was that “the pain also influences his or her assessment of single most reliable indicator of the existence and patients’ pain. intensity of acute pain-and any resultant affective Patient coping mechanisms. Patients exhibit a discomfort or distress-is the patient’s ~elf-report.”~wide range of coping mechanisms when dealing with Nursing assessments of a patient’s pain level are influ- pain. Some talk and laugh, some lie perfectly still, enced by a variety of factors, including the patient’s and others writhe and moan. The self-reporting pain 935 AORN JOURNAL
DECEMBER 1996, VOL 64,NO 6 Campese 9
scale allows each patient to identify his or her own level of pain regardless of how the nurse is influenced by other factors. Medications. During the inservice education program, nurses described situations in which they were unsure when patients needed analgesics. The scenario of a patient who had been sleeping soundly, then woke up complaining of severe pain was familiar to many of the nurses. They did not think pain medication was really necessary in such situations, because they could not understand how a patient in pain could sleep. The inservice program alerted the nurses to the fact that the commonly ordered combination of meperidine hydrochloride and promethazine hydrochloride may not be the most effective treatment for postoperative pain. Meperidine hydrochloride commonly is underdosed and administered too infrequently,Eand promethazine hydrochloride causes sedation, thus creating the appearance of pain relief. The nurses realized that although they cannot change the medication a physician prescribes, they can-indeed, they have an obligation to-call the physician any time a patient does not achieve an acceptable level of pain control. Ideally, the physician would then order a higher dosage of the medication or prescribe a different analgesic. The surgical services quality improvement coordinator encouraged the nurses to make the commitment to their patients to provide an acceptable level of pain control. During the inservice program, she also instructed the nurses to know how and when to teach the use of the pain level scale, how to assess the pain that patients experience (eg, location, quality, onset, duration), and the proper method for documentation. Some of the nurses practiced relaxation breathing techniques during the inservice program, and the surgical services quality improvement coordinator encouraged them to help their patients use relaxation breathing, music therapy, and other comfort measures to relieve postoperative pain. She reinforced the concepts taught during the inservice program by making available to each unit a videotape of the education program; copies of the patient letter detailing the pain management program and use of the pain level scale; and the AHCPR clinical practice guidelines, quick reference guidelines, and patient guides for pain management.
mNALpRIpAnATmN
By December 1994, we had presented the inservice education program for all nursing units at St Mary’s. To remind staff members of the Jan 1, 1995, pain management program implementation date, we hung posters and sent memoranda to all nursing units. In addition, some nursing units laminated enlarged copies of the pain level scale and hung them at the nursing stations and in patient rooms. The pediatric unit head nurse revised the pain level scale to make it easier for children to recognize the various levels of comfort. She also revised the patient letter to explain the use of the scale in age-appropriate terms. According to the AHCPR guidelines, children ages four years and older are able to use the scale. For younger children and infants, we planned to work with the parents and use their assessments of children’s pain (eg, children’s behavior) to evaluate the levels of pain the children were experiencing. IMPUMINTAWON
We supplied each nursing unit with copies of the adult and pediatric versions of the patient letter. When a patient was admitted to St Mary’s, a nurse would give a copy of the letter and pain level scale to the patient during the initial assessment and teaching period. We believed that providing each patient with the letter represented a written contract that stated we intended to do our utmost to help the patient achieve postoperative pain control. The NQIC members and the head nurses were excited about the new program, but many of the staff nurses expressed doubtful opinions such as “It’s one more piece of paper” or “One more thing to remember to do and to chart.” The NQIC members encouraged the staff nurses to express their thoughts and ideas about the program and reminded them that the first three months were a trial period and that program revisions might be necessary. Based on their experiences with the patients, the staff nurses would be the first to recognize the potential areas for revision. As with many new programs, initial compliance by the nursing staff members began slowly. As each nurse gained experience with teaching the pain management program and helping patients use the pain level scale, however, we began hearing success stories from both nurses and patients. One nurse related the story of a pediatric patient who was recovering from abdominal surgery. The child emerged from the bathroom pointing to the big
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symptoms required surgery. We do not perform cardiac surgery at St Mary’s; therefore, the admission of a patient for cardiac surgery would be a rare occurrence. The director of nursing supported the decision to use the two scales and asked that docuPostanesthesia care unit modifications. mentation be adapted to encompass the two scales. Although the scale was a good tool for some PACU Nurses now chart pain levels with a split number to patients, the self-report was inappropriate for some indicate which scale they are using. The first numpatients. After much discussion, the PACU nurses ber represents the patient’s level of pain. The second decided to medicate their patients based on a nursing number represents which scale is being used. For assessment of nonverbal behaviors (Table 1) until example, a pain level of four on the five-point scale is documented 415; a level of five on the 10-point scale is documented 5/10. Table 1 Pilot approved. The remainNONVERBAL PAIN SCALE der of the three-month trial periCode Word scale Nonverbal behavlors od passed fairly smoothly. On April 1, 1995, after approval by 1 No pain Relaxed, calm expression the medical staff members, all St 2 Slight or mild pain Stressed, tense expression Mary’s patients were added to the
smile on his own face. The nurse was puzzled at first but the child’s mother explained, “He’s showing you his smile, like the one on the scale.” Another PACU nurse told of her patient who waved four fingers to indicate his level of pain.
3
Moderate pain
Guarded movement, grimacing
pain management program. We were encouraged to 4 Severe pain Moaning, restless note AOFW’s “Perioperative nurse 5 Worst pain Crying out, increased intensity translation of the AHCPR clinical practice guidelines,” which was of above behaviors published in the 1995 edition of A standards and Re (Adapted with permission from St Mary‘s Healih Care %stern, In@, Ahens, Ga) mended practice^.^ We believe our program aligns closely with patients were alert enough to self-report their pain. AORN’s translation of the AHCPR guidelines. If possible, PACU nurses elicit patients’ self-reported levels of pain before transferring them to postop- P R - ~ EXPANerative nursing units. This initial assessment estabWe had informed the ancillary quality improvelishes a baseline for the nursing unit staff members ment council (AQIC), a multidisciplinary committee to use when evaluating patients’ postoperative pain consisting of representatives from every area of the management. hospital system, of our intent to focus on pain manageEmergency department modifications. ED ment. As our program evolved, we kept AQIC memnurses identified another issue concerning the use of bers apprised of its progress. Eventually, the AQIC the five-point pain scale. The cardiologists serving adopted pain management as a systemwide focus. our hospital requested that their patients use a 10Concurrent with the development and implepoint pain scale when evaluating their chest pain. mentation of the pain management program, the The cardiologists believe that the 10-point scale director of St Mary’s quality improvement center, gives a more accurate picture of pain and the control who was also the AQIC chairman, formed a quality achieved. team specifically to address pain management. The NQIC discussed this issue in depth at ‘its The quality team for pain management initially had February 1995 meeting. Proponents of each scale representatives from nursing, surgical services, pharvoiced opinions, and the decision was made to con- macy, and continuous quality improvement departtinue using the five-point scale for all patients ments. Representatives from the long-term care except those referred for cardiac problems. We facility, rehabilitation, hospice, and home health understood that the use of two scales might cause joined shortly thereafter. some confusion, especially if a patient with cardiac The quality team identified the need to monitor 938 AORN JOURNAL
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Figure 3 Nonverbal 1 0-point pain level scale. the pain management program by focusing on medication utilization evaluation. Those patients who did not have their pain controlled at a level three or less on the five-point scale would be identified and their medical records reviewed using criteria approved by the medical staff pharmacy committee. We decided to study patients on the surgical nursing unit that had been using the pain scale for two years. We also included PACU patients who had extended stays in the PACU for pain control. The quality team was unable to draw conclusions based on the initial data collected about patients with pain levels of three or above. The team decided that the patient population studied was too broad and lacked a comparable control group and information was missing (eg, If a patient did not achieve pain control, did a nurse seek a change in medication? Was the pain medication given on a timely basis?). To more clearly focus the study, quality team members agreed on two statements. Patients having total knee replacement procedures experience the greatest amount of postoperative pain. Patients who use a patient-controlled analgesia (PCA) pump achieve the best pain control. Using these statements as a baseline, the quality team members are planning a retrospective review of medical records of all patients who have undergone total knee replacement to compare medication cost and efficacy. The quality team also selected these patients for study because the hospital performs a sufficient number of the procedures each year and patient length of stay for this procedure is long enough to generate useful information. Data gathered will include route and dosage of pain medication, type of anesthesia administered, total morphine equivalency,
length of stay, use of PCA, and adjunctive administration of nonsteroidal antiinflammatory medications. EVALUATION
Our program is still in its infancy, and it will be some time before we have enough data to draw specific conclusions. Hospitalwide, we are measuring the program’s success by using the results of an independent firm’s surveys of inpatient and outpatient satisfaction with many aspects of the hospital’s functions. The consulting fm compares our results with those from other hospitals of the same size and type. Our goal is to maintain a raw patient satisfaction score above 90 for the question “How well was pain controlled?” For the time period of Feb 1, 1995, through May 1, 1995, our raw score was 92.1, placing St Mary’s in the 99th percentile for this question when compared with 360 similar hospitals nationwide. Concurrently, NQIC members reviewed documentation of patient teaching related to pain management and noted that compliance increased as the program gained acceptance. The NQIC members also reviewed medical records for documentation of patients’ levels of pain using either the five-point or 10-point pain scale and noted that compliance increased over time. The NQIC members, however, encountered some difficulty interpreting the documentation due to the use of two pain scales. To provide for consistency in documentation, the NQIC voted to use only the 10-point scale (Figure 3) and instituted this change in early 1996. We revised the policy, procedure, and nonverbal behavioral scale to reflect use of the 10-point scale. Our 1996 assessment of the pain management program will use the independent survey firm results, as well as the review of documentation in patients’ medical records. All hospital nursing units
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are using the same study criteria now that the program is implemented. CONCLUSIONS AND RECOMMENDATIONS
In September 1995, St Mary’s underwent a mock JCAHO survey. The surveyors were impressed with the quality and content of the pain management program and stated that we should share our information with other facilities. The surveyors suggested that we offer more music therapy as part of the pain management program. One way to include music therapy is to educate patients on the benefits of music and provide audiotapes for patients to use. The pain management program is now recognized by hospital staff members as an important aspect of quality patient care. Quality improvement committee members will update staff members on the progress of the program, and we also will provide progress reports via storyboards placed throughout the hospital. The NQIC and the quality team members hope to draw specific conclusions about the quality of pain control patients achieve to identify best practices. The knowledge gained also will be used in developing critical pathways. Our ultimate goal is to provide all patients exceptional care and optimal outcomes. We believe that this information about our pain management program’s development can help other facilities that wish to develop pain management programs of their own. Questions to consider when contemplating the establishment of a pain manageNOTES 1. Agency for Health Care Policy and Research, Management of Cancer Pain, Clinical Practice Guideline (Rockville, Md: US Department of Health and Human Services, 1994). 2. Agency for Health Care Policy and Research, Acute Pain Management in Infants, Children, and Adolescents: Operative and Medical Procedures, Quick Reference Guide for Clinicians (Rockville, Md US Department of Health and Human Services, 1992). 3. J DiGregorio, Handbook of Pain Management, third ed (West Chester, Pa: Medical Surveillance, 1991). 4. Joint Commission on Accreditation of Healthcare Organizations,
ment program follow. What should the program accomplish specifically? Are physicians supportive? What resources will be necessary? What department or team will be responsible for developing the program? Which pain level or visual analog scale best meets the needs of patients seen at the facility? How will information about the program be dispersed to staff members and patients? What data will be collected, and how will they be collected? We encourage other health care facilities to recognize pain control as an important aspect of care. Adequate pain control facilitates patient comfort, promotes postoperative healing, and increases patient satisfaction. Through collaborative efforts, health care professionals can care effectively for patients who are experiencing pain. A Claudia Campese,RN, BS, CNOR, is an OR staff nurse at St Mary’s Health Care System, Inca, Athens, Ga. She was the quality improvement coordinator for surgical services at St Mary’s at the time this article was written.
The author would like to acknowledge Lorraine Spann Edwards, director of public relations, and Kymy Pruitt, RN, BSN, MEd, project manager, clinical process redesign, St Mary’s Health Care System, Inca, Athens, Ga,for their assistance with this article.
“Agenda for change: Q & A,” Perspectives 12 (JanuaryPebruary 1992). 5. “Hospital uses federal guidelines to create its policy on pain,” Hospital Peer Review 19 (September 1994) 140-141. 6. St Maiy’s Health Care System, In@, Pain Management Policy (Athens, Ga: St Mary’s Health Care System, In@, 1995). 7. M McCaffery, A Bebee, Pain: Clinical Manual for Nursing Practice (St Louis: Mosby, 1989). 8. B Reed, J Alexander, J Rice, “Management of the patient in pain: Nursing implications,” seminar presented at Habersham County Medical Center, Demorest, Ga, November 1994. 9. K Schmidt et al, “Implementa940 AORN JOURNAL
tion of the AHCPR pain guidelines for children,” Journal of Nursing Care Quality 8 (April 1994) 68-74; “Perioperative nurse translation of the AHCPR clinical practice guidelines,” in AORN Standards and Recommended Practices (Denver: Association of Operating Room Nurses, Inc, 1995). SUGGESTED READING Guyton-Simmons, J; Ehrmin, J T. “Problem solving in pain management by expert intensive care nurses.” Critical Care Nurse 14 (October 1994) 37-44. Tieman, P. “Independent nursing interventions: Relaxation and guided imagery in critical care.” Critical Care Nurse 14 (October 1994 ) 4751.