Pain management: An organizational commitment

Pain Management: An Organizational Commitment yyy Marybeth Ryan, PhD, RN, CNS, ANP,*†‡ Deborah Ann Ambrosio, MS, RN,†§‡ Catherine Gebhard, MSN, RN, CNS,‡ and Jennifer Kowalski, BSN, RN§‡

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ABSTRACT:

Although much has been done to promote pain assessment and management, pain remains a major, yet largely preventable, public health problem in the United States. A strategy that has been proposed to assure optimal pain management is the development of formal means within institutions to evaluate pain management practices and foster improved outcomes. In response to a pain-related patient care problem, South Nassau Communities Hospital recognized the need to undertake more formal methods for managing patients with acute, chronic, and cancer pain. A Pain Management Task Force was charged with the development of a comprehensive pain management program. Its efforts to date and plans for the future position this institution as ready for the Joint Commission for the Accreditation of Healthcare Organizations’ pain assessment and management standards that were introduced in 2000. © 2000 by the American Society of Pain Management Nurses

From the *Nurse Practitioner Program, Adelphi University, †School of Nursing, Garden City, NY; and the §Performance Improvement Department, ‡South Nassau Communities Hospital, Oceanside, NY. Address reprint requests to Marybeth Ryan, PhD, RN, CNS, ANP, South Nassau Communities Hospital, 2445 Oceanside Road, Oceanside, NY 11572. E-mail: [email protected]. © 2000 by the American Society of Pain Management Nurses 1524-9042/00/0102-0005$3.00/0 doi: 10.1053/jpmn.2000.8322

In the past several years, health professionals, consumers, regulatory bodies, and health policymakers have become increasingly aware of the need for improved pain therapies to remedy the less than optimal management of pain that has existed for decades (American Academy of Pain Medicine, 1999; Gordon, Dahl, & Stevenson, 1997). There is a growing body of evidence that unrelieved pain is associated with many physiological and psychological risks. The reduction of these risks through aggressive pain prevention and control can produce both short- and long-term positive outcomes for patients (Gordon et al, 1997). The early part of the last decade saw the U.S. Department of Health and Human Services’ dissemination of the Agency for Health Care Policy and Research (AHCPR) Clinical Practice Guidelines for the management of acute and cancer pain (Department of Health and Human Services, 1994; 1992a; 1992b). In addition, the literature is replete with articles addressing the need for better assessment and management of acute, chronic/nonmalignant, and cancer pain (Allegrante, 1996; Bookbinder et al, 1996; Ferrell, 1999; Georgesen, 1999; Katz, 1996; Manning, Lands, & Jones, 1999; Seers & Carroll, 1998; Weisberg & Clavel, 1999). Pain Management Nursing, Vol 1, No 2 (June), 2000: pp 34-39

Pain Management: An Organizational Commitment

Despite the advocates for and all of the work performed to promote pain assessment and management, pain remains a major, yet largely preventable, public health problem (Joint Commission for the Accreditation of Healthcare Organizations, 1999). Traditional patterns of practice regarding pain management within the nation’s health care institutions have been identified as the most formidable barrier to the solution of this problem. In an attempt to impact pain from a broader health care system perspective, beginning in 2000, pain assessment and management will be integrated into the Joint Commission for the Accreditation of Healthcare Organizations’ (JCAHO) standards, intent statements, scoring guidelines, and survey process. The new standards will appear in the 2000-2001 accreditation manual and will be first scored for compliance in January, 2001 (Cross, 1999; Dahl, 1999). The standards will require hospitals, home care agencies, nursing homes, behavioral health care facilities, outpatient clinics, and health care plans to: ● Recognize the right of patients to appropriate assessment and management of pain; ● Assess the existence and, if so, the nature and intensity of pain in all patients; ● Record the results of the assessment in a way that facilitates regular reassessment and follow-up; ● Determine and assure staff competency in pain assessment and management; ● Address pain assessment and management in the orientation of all new staff; ● Establish policies and procedures that support the appropriate prescription or ordering of effective pain medications; ● Educate patients and their families about effective pain management; ● Address patient needs for symptom management in the discharge planning process. (JCAHO, 1999, p. 1)

HISTORICAL OVERVIEW/RATIONALE FOR INITIATION OF THE PAIN MANAGEMENT TASK FORCE The process of institutionalizing pain management is not defined by walls or buildings, but rather by groups of health care providers organized to be proactive about pain management (Dahl, 1999). One strategy that has been urged to assure optimal pain management is the development of formal means within institutions to evaluate pain management practices and work to continuously improve outcomes (Gordon et al, 1997). This article presents a chronological account of South Nassau Communities Hospital’s efforts to develop a comprehensive pain management program for patients with acute, chronic, and cancer pain. In September of 1998, a Task Force at South Nassau Communities Hospital, a full-service, 429-bed,

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not-for-profit facility, convened in response to a patient-related occurrence involving intravenous patient controlled analgesia (PCA). The Nursing Performance Improvement Coordinator established an interdisciplinary Task Force consisting of members of the Nursing, Pharmacy, and Anesthesia departments to further address the issue. An interdisciplinary approach was chosen because no single method, individual, or discipline can conquer pain management (Pasero, McCaffery, & Gordon, 1999). A case review focused on the feasibility of pump failure, human error, documentation, and quality control. A process problem was identified and recommendations for improvement included: ● Revision of the PCA flow sheet; ● Changes on various forms in the medical record to reflect the AHCPR guidelines pain scale 0-10; ● Development of a PCA policy and revision of procedures; ● A quality control audit, conducted by the pharmacy department, to ensure accuracy of the medication cassette (content and volume); ● Development of an organizational, interdisciplinary comprehensive pain management program.

The Task Force’s vision was to create a pain management program that would standardize pain management in the institution and provide for the delivery of quality care to all patients. Quality care relates to processes that cut across organizational lines and accepts that quality is about getting better, and striving for perfection. Recommendations for process improvements were submitted in February, 1999, to the Performance Improvement Steering Committee (PISC), the coordinating group responsible for planning a systematic, hospitalwide approach to improving patient care and health outcomes. The PISC recognized that a comprehensive pain management initiative was congruent with the hospital’s mission, vision, and values as well as the strategic planning priority of improving patient outcomes. As the hospital prepared for a JCAHO site visit, it was recognized that the JCAHO pain management standards that were on the horizon would have to be addressed. Because efforts to develop a pain management program had previously focused only on patients with cancer pain and, therefore, had not been comprehensive, the PISC, in July 1999, chartered a new Pain Management Task Force. The appointed chairperson of this group, an anesthesiologist, and the facilitator, the Nursing Performance Improvement Coordinator, were empowered to invite members of the health care team who would be devoted to ensuring the assessment and management of pain as a patient care priority. Because of the group’s cohesiveness, the original Task Force members were invited to participate in

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the new endeavor to develop a comprehensive institutional pain management program.

REDEFINING THE PAIN TASK FORCE: GOALS AND AGENDA The initial meeting of the Task Force took place in May 1999. The first order of business was to establish goals. The goals identified included: ● To develop guidelines for the assessment, intervention, and evaluation of all patients with acute, chronic, and cancer pain; ● To ensure assessment of pain for all South Nassau Communities Hospital patients as well as outpatient/off-site clients; ● To provide pain management for all patients, at all centers of care, via an interdisciplinary approach.

To address these goals, members were assigned various tasks including an assessment of mechanisms that were in place in the institution across the continuum of care that identified patients in pain. Because the team recognized the value of their colleagues’ efforts at other institutions in regard to pain management and wanted to network with these resources, team members were assigned the responsibility of contacting these individuals to determine the existence of other pain management programs. Information gleaned from a literature search also was very valuable in directing the Task Force’s early efforts, particularly the work of Gordon et al (1997), Pasero et al (1999); and Talavinia-Pasek (1995). By using a template from the Wisconsin Resource Manual for Improvement (Gordon et al, 1997), a timeline was developed. Further tasks identified included: ● Adoption of uniform measures for assessing pain management, including a uniform method of documentation; ● Education of all caregivers to analgesia intervention, as well as nonpharmacological modalities; ● Development/revision of policies and procedures for pain management; ● Education of patients and families regarding the institution’s pain management initiative; ● Identification of performance improvement activities and accountability for pain management.

REVIEW OF CURRENT PAIN PRACTICES WITHIN THE INSTITUTION Review of current pain practices evidenced that many appropriate pain assessment and management efforts were in place. Nurses were being educated during orientation about acute, chronic, and cancer pain man-

agement. Content on assessment, pharmacological, and nonpharmacological interventions, and barriers to effective treatment were discussed. It was identified, however, that measurement of the baseline knowledge of these nurses regarding pain management and postmeasurement of knowledge acquired should be incorporated into this educational process. Inservices were being given regarding the specific needs and management of relevant patient populations (eg, neonate to elderly, patients with postoperative acute pain as well as cancer pain). Nurses in specific patient care units were expected to show competence annually in pain assessment and intervention, use of the PCA pump, and care of the patient receiving epidural analgesia. The AHCPR guidelines appropriate to the patient population were available on nursing units as a resource for clinicians and patients. On admission, each patient was being assessed for pain and the findings were documented on the Admission History and Data Base form. Additionally, the use of pain flow sheets provided both a means of documenting patients’ pain level and response to intervention, as well as a method of assessing the need for further intervention.

STANDARDIZING PAIN MANAGEMENT EFFORTS An initial task of the team was to write a hospitalwide policy on pain management. Because there were several overlapping policies and procedures in place in relation to pain management, these were condensed into two policies and procedures: “Administration of Patient Controlled Analgesia,” and the “Administration of Epidural Analgesia.” Concurrently, the Standards of Patient Care Committee updated the standard on “Care of the Patient Experiencing Pain.” The Task Force identified that consistency was needed in the use of a pain measurement scale throughout the hospital community. This need was validated by a chart review. A uniform measurement of pain was instituted via the use of a 0-to-10 scale. The pain scale ruler, given to each nurse during orientation, has a visual analogue scale in color, numbers and words on one side, and a face analogue scale on the other to be used as appropriate to patients’ developmental/cognitive status. It was agreed that the current flow sheet for non-PCA/epidural pain management also needed to be revised.

COORDINATING EDUCATIONAL EFFORTS The Pain Task Force further identified that housewide educational efforts were needed. The first workshop

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Pain Management: An Organizational Commitment

TABLE 1. Statement on Pain Management All Patients Have a Right to Pain Relief Our Health Care Providers will: ● Inform patients that relief of pain is an important part of their care and respond quickly to reports of pain. ● Ask patients on interview and as part of regular assessments to describe their pain. ● Work together with all patients and other health care providers to set goals for pain relief when necessary and achieve those goals. ● Change the plan of care for patients when pain relief is not satisfactory. Courtesy of South Nassau Communities Hospital.

given in the Fall of 1999 by a Task Force member, the Medical-Surgical Clinical Nurse Specialist, was entitled, Pain is Real—Knowledge is Power. This program was an in-house, 1-hour session, offered 3 times, to which all disciplines were invited. In addition, to better educate patients, an informational statement on patients’ right to having their pain addressed, which was

adapted from the Wisconsin Resource Manual for Improvement (Gordon et al, 1997), has been written and is being placed in each patient’s admission packet (see Table 1). The Task Force organized a Pain Awareness Week for January 17-21, 2000, directed toward educating the multidisciplinary members of the institution’s

TABLE 2. Pain Awareness Week Brochure PURPOSE: To educate the multidisciplinary members of South Nassau Communities Hospital health care providers across the continuum of care. Statement on Pain Management All Patients Have a Right to Pain Relief. Our Health Care Providers will: ● Inform patients that relief of pain is an important part of their care and respond quickly to reports of pain. ● Ask patients on interview and as part of regular assessments to describe their pain. ● Work together with all patients and other health care providers to set goals for pain relief when necessary and achieve those goals. ● Change the plan of care for patients when pain relief is not satisfactory.

Interventional Pain Management Monday, 1/17 Albert Conf. Rm. 7:30-8:30am Comprehensive Pain Management for the Internist Tuesday, 1/18 Albert Conf. Rm. 8:00-9:30am Nonpharmacological Treatment of Pain Wednesday, 1/19 Albert Conf. Rm. 9:30-3:30pm See Registration Form Pain Management for Labor and Delivery Thursday, 1/20 Albert Conf. Rm. 8:00-9:00am Assessment and Management of Chronic and Acute Pain Thursday, 1/20 Albert Conf. Rm. 3:00-5:00pm

REGISTRATION FORM Wednesday 1/19/2000 Albert Conference Room Nonpharmacological Treatment of Pain 9:30-10:05am Integrative Pain Management Acupressure/ Acupuncture 10:05-10:35am **Break** Nursing Implications for Nonpharmacological Pain Management 11:05-11:35am 11:35-12:00N Panel Discussion Lunch (Provided) 12:00-1:00pm Therapeutic Touch 1:05-1:35pm Guided Imagery 1:35-2:00pm WORKSHOPS Please check one workshop for each time you wish to attend. Return promptly by 1/13/2000. Space is limited (Room TBA)

Pain Management for Medical Specialists—What We Know and What We Need to Know Friday, 1/21 Albert Conf. Rm. 8:30am

2:15– A B C 2:45 Therap. Touch Guided Imag. Hypnosis 2:45– D E F 3:15 Therap. Touch Guided Imag. Hypnosis NAME DEPT

Ext

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continuum of care (see Table 2 for one page of the brochure developed for this event). Speakers selected were experts in their fields and included neurologists, internists, an anesthesiologist, mental health clinicians, and clinical nurse specialists. Lectures included both pharmacological and nonpharmacological topics. One day’s focus was solely on alternative/complementary strategies and treatments available to patients. The hospital administration showed its strong commitment to the success of the endeavor by providing resources including honoraria for the presenters who spoke on nonpharmacological topics, printed materials, refreshments, and a luncheon. Costs were contained by having various pharmaceutical companies sponsor the majority of the speakers. Similar to the Pediatric Pain Awareness Week described by Talavinia-Pasek (1995), plans for a captive audience were ensured by coordinating speakers’ presentation on pain topics with regularly scheduled weekly hospital departmental meetings (eg, medicine, surgery, pediatrics, and nursing council). A major intent of the week was to expose participants to the nonpharmacological alternative/complementary modalities that are used for pain management and symptom control. An extensive bibliography was distributed at the conference, and a resource manual with relevant medical and nursing journal articles pertaining to this aspect of pain management has been added to the hospital’s medical library collection. Select videos from a series on pain management, purchased by the hospital, also were shown during the week and are now housed in the medical library. Eight of these videos have a manual and posttest available for continuing education use. Included in this series is content related to infants and children (Broome, 1994; McCaffery, 1992; McCaffery, Ferrell, Williams, & Pasero, 1995; Paice, 1994, 1997; Stevens, 1994). Finally, to further educate participants about the new JCAHO standards for pain assessment and management, a flyer with these aforementioned standards was distributed at each session. The programs were well-attended by several disciplines. The success of the program was measured by using a written program evaluation tool. All evaluations were favorable, describing the programs as informative, well-organized, focused, and useful for clinical practice. The speakers were described as knowledgable about the topic and sincere with a passion for pain management. Valuable information from the over 250 participants included content suggestions for future programs such as chronic pain, community education, more information regarding pain resources, current medication therapy, and pain management for specific populations, such as pediatric and obstetric patients.

PAIN-RELATED PERFORMANCE IMPROVEMENT EFFORTS The methodological framework for performance improvement at South Nassau Communities Hospital is plan, design, measure, assess, and improve. Continuous quality improvement is achieved through assessing, measuring, and monitoring. Ongoing measurement enables an organization to judge the stability of a process and the predictability of outcomes (JCAHO, 1996). The intent is to reduce variation in practice and deliver positive patient outcomes. The Pain Task Force wants to ensure that service is being provided to all patients to achieve the goal of comprehensive and individualized pain management. A measurement method currently in place involves the Patient Survey Nurse contacting all in-hospital discharged patients and ambulatory surgery patients by telephone within 24 hours to identify patients’ pain ratings. This measurement method will continue to be used and will be expanded to include all patients across the continuum of care who will be managed by the proposed clinical pain management team. Increasing patient satisfaction while providing quality pain management is still another goal. The Task Force has chosen to use the results from Press, Ganey Associates, Inc. (1999) quarterly patient satisfaction survey reports regarding pain control during hospitalization to determine if this goal is being met. These data also will provide the organization with comparative information.

FUTURE PLANS OF THE TASK FORCE Although pieces already have been initiated to address the multiple facets of developing a comprehensive pain management program, the team still has goals to meet. First, an interdisciplinary clinical pain management team needs to be established with guidelines as to its function and accountability. Secondly, a screening process, with criteria for patient assessment and follow-up, needs to be constructed. Thirdly, a referral system will be devised whereby patients who need the intervention of the clinical pain management team will be assessed in a timely manner. Finally, other program evaluation methods will be identified and implemented to determine the efficacy and effectiveness of the organization’s pain management program. As identified goals are achieved and quality pain management strategies give patients the opportunity to control their pain, the health care providers at South Nassau Communities Hospital will be ensuring comprehensive pain management and touching lives one patient at a time.

Pain Management: An Organizational Commitment

ACKNOWLEDGMENT The authors wish to gratefully acknowledge Neil Kirschen, MD, Edward De Lucie, RPh, and Jacki Rosen, RN, CNS, for their review of the manuscript, and John Mazzei for his technical assistance in its preparation.

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Resource Manual for Improvement. Madison, WI: Wisconsin Cancer Pain Initiative, 1997 Joint Commission on Accreditation of Healthcare Organizations. Joint Commission focuses on pain management [On-line]. Available: http//www.jcaho.org/news/ nb207.html, 1999 Joint Commission on Accreditation of Healthcare Organizations. Comprehensive accreditation manual for hospitals. The official handbook. Oakbrook Terrace, IL: Author, 1996 Katz WA. Approach to the management of nonmalignant pain. The American Journal of Medicine 101(Suppl 1A), 54S-63S, 1996 Manning C, Lands R, Jones M. The team approach to pain management: A critical pathway. Oncology Pain Management 27-32, 1999 McCaffery M. McCaffery on pain: Nursing assessment and pharmacologic interventions in adults. Baltimore, MD: Williams and Wilkins Electronic Media, 1992 McCaffery M, Ferrell BR, Williams A, Pasero C. McCaffery: Contemporary issues in pain management. Baltimore, MD: Williams and Wilkins Electronic Media, 1995 Paice JA. Physiology of pain: Unraveling the mystery. Baltimore, MD: Williams and Wilkins Electronic Media, 1994 Paice JA. Pharmacologic management of pain: Tools for treatment. Baltimore, MD: Williams and Wilkins Electronic Media, 1997 Pasero C, McCaffery M, Gordon D. Build institutional commitment to improve pain management. Nursing Management 30(1), 27-32, 1999 Press, Ganey Associates, Inc. Understanding your Press, Ganey reports . . . the next step toward Performance Improvement. South Bend, IN: Author, 1999 Seers K, Carroll D. Relaxation techniques for acute pain management: A systematic review. Journal of Advanced Nursing 27, 466-475, 1998 Stevens B. Pain in infants and children: Confronting the challenges. Baltimore, MD: Williams and Wilkins Electronic Media, 1994 Talavinia-Pasek T. Education during Pediatric pain awareness week. Maternal Child Nursing 20, 153-155, 1995 Weisberg MB, Clavel AL. Why is chronic pain so difficult to treat? Postgraduate Medicine 106(6), 141-164, 1999