Pain management—Continuum of care for surgical patients

Home Study Program

SEPTEMBER 2003, VOL 78, NO 3

Home Study Program Pain managementContinuum o f care for surgical patients

T

he article ”Pain management-Continuum of care for surgical patients” is the basis for this AORN Journal independent study. The behavioral objectives and examination for this program were prepared by Rebecca Holm, RN, MSN, CNOR, clinical editor, with consultation from Susan Bakewell, RN, MS, education program professional, Center for Perioperative Education. Participants receive feedback on incorrect answers. Each applicant who successfully completes this study will receive a certificate of completion. The deadline for submitting this study is Sept 30,2006. Complete the examination answer sheet and learner evaluation found on pages 403-404and mail with appropriate fee to

AORN Customer Service c/o Home Study Program

2170 S Parker Rd, Suite 300 Denver, CO 80231-5711

This PWmm meets criteria for CNOR and CRNFA mertification as well as other continuing education requirements. A minimum score of 70%

or fax the information with a credit card number to (303) 750-3212. You also may access this Home Study via AORN Online at http..//www.aorn.oqflourna~homes tudy/deefoult.htm.

BEHAVIORALOBJECTIVES After reading and studying the article on pain management-continuum of care for surgical patients, nurses will be able to

on the multiple-choice examination is necessary to earn 3.6 contact hours for this independent study.

1. explain the rationale that justified the need for a pain management process improvement (PI)project;

2. discuss how the FOCUSPDSA (ie, find, organize, clarify, understand, stabilize-plan, do, study, act) strategy was used to detect major issues that PI team members felt needed to be resolved;

3. describe the PI action plan established to resolve identified pain management problems in both facilities; and

4.

discuss whether established goals were accomplished by the PI project.

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Home Study Program Pain managementContinuum of care for surgical patients Sharon W. Chavis, RN; Linda H. Duncan, RN

P

a h management is a hot topic in health care today, in part because of the Joint Commission on Accreditation of Healthcare Organizations’ (JCAHOs) standards for pain management.

“The patient’s right to pain management is respected and supported. The health care organization plans, supports, and coordinates activities and resources to assure the pain of all patients is recognized and addressed appropriately.”I (p N14-14a) With this goal in mind, Centra Health surgical services division became proactive in improving pain management for surgical patients. Lynchburg General Hospital (LGH), Lynchburg, Va, and Viiginia Baptist Hospital (VBH), Lynch-

ABSTRACT A PAIN MANAGEMENT PROCESS IMPROVEMENT TEAM was created to develop a unified and consistent way to address pain management for surgical patients. TEAM MEMBERS EVALUATED patient satisfaction ratings, patient and family member education, use of specific pain scales, patient comfort function goals, staff member education, and use of physician standing orders and protocols. TEAM MEMBERS WERE PROACTIVE in their efforts to improve pain management outcomes for surgical patients and to improve patient satisfaction. They also integrated protocols to comply with pain management standards established by the JointCommission on Accreditation of Healthcare Organizations.AORN 78 (Sept 2003) 382-399.

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burg, Va, comprise the acute care settings for outpatient and inpatientsurgicalservices of Centra Health, a nonprofit health care system in central Virginia. Bedside clinical nurses were the driving force behind the pain management initiative.A core group of nurses recognized the need for a more consistent way to address pain management for surgical patients. Preexisting processes reflected that patient care delivery on each hospital campus and in each area of surgical services operated independentlyinstead of collaboratively in efforts to manage patients’ comfort and function levels. For example, the pain scales used varied from area to area (eg, zero to five, zero to 10, faces, behavioral). In addition, patient needs were being met with respect and considerationonly to a specified end point of service. A fragmented approach in the delivery of patient care and pain management was evident. A group of perioperative nurses at Centra Health who are dedicated to improving pain management recognized the need to develop a comprehensiveand collaborative approach to pain management. The group submitted a request to administrators to form a service-wide performance improvement (PI) team with an ultimate goal of improving pain management. Upon receiving full approval, a team consisting of dedicated nursing staff members, surgeons, methesia care providers, pharmacists, and other key hospital personnel was formed. Team members were hand selected for the group and soon became the surgical services PI team for pain management. RATIONALE AND

BACKGROUND

The PI team members included representatives from both campuses and all involved departments, including

thesia care providers managed patients until they were discharged from the hospital. At VBH, anesthesia care providers concluded their management of patients after they were discharged from the PACU, which left the surgeon responsible for managing patients’ postoperative pain in phase 11 recovery. These two anesthesia practices created conflicting routines for nurses at both hospitals. Contacting physicians and obtaining orders to medicate patients for pain in a timely manner frequently was a problem. To complicate the issue, individual surgeons varied greatly in regard to pain management and medication preferIDENTIFICATION OF MAJOR ISSUES The PI team developed and ence. No standardized physician order launched a course of action using the set or protocol for postoperative pain FOCUS-PDSA process improvement management was available. NURSING DOCUMENTATION PROCESS. Team strategy. This process entails 0 F-finding a process that needs members identified both inconsistencies in and lack of required elements in improvement, the nursing documentation process.l 0 k r g a n i z i n g a project team, Team members performed chart audits 0 C-clanfying the process, in October 2001 using six standards of 0 U-understanding the process, and measurement that identified specific 0 S--stabilizing the process. The PDSA (ie, plan, do, study, act) cycle pain-related issues linked to surgical within the FOCUS strategy ensures patients (Figures 1 and 2). It became that the situation is adequately evident that the available nursing tools assessed (ie, plan), a plan is coopera- and forms were not designed to captively determined and implemented ture the critical elements outlined in (ie, do), the results are evaluated (ie, the standards. Chart audits reflected study), and the improvement is stan- documentation deficiencies in dardized (ie, act).2Project improvement 0 education of patient and family memteam members created a flowchart to bers regarding pain management; map out the step-by-steppain pathway 0 preoperative assessments for pain most common to surgical patients. This management; tool allowed team members to idenbfy 0 use of appropriate pain scales; multiple issues from which to develop 0 reassessments, monitoring, and inaction plans. terventions to pain management; and Team members also included consultants from the pharmacy department and the Centra Health pain council. Additionally, it was determined that input from the department of anesthesia would be vital in ensuring the implementation and success of any improvements in pain management for surgical patients; therefore, individuals (ie, key champions) from the anesthesia department at each campus who were known to have vested interest in pain management were approached. They willingly agreed to serve as a critical resource for team members.

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discharge planning specific to pain management. STAFFMEMBER COMPETENCY. Team members also determined that staff member knowledge and competency levels in regard to pain management (eg, pain scales, sedation scales, pharmaceutical implications) should be enhanced. This issue was identified through informal needs assessment discussions with staff members. In addition, team members recognized the need to include physicians in the education process by sharing information with them to heighten their awareness and knowledge. Mormation obtained from a 12-month medication utilization review for surgeons and anesthesia care providers also was shared as an overview of current clinical practice (Tables 1 and 2).

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team developed process improvement action plans for each of the major issues identified. The key issues were consolidated, and priorities were set to include 0 documentation, 0 patient and family member education, 0 staff member education, 0 physician orders and protocols, and 0 physician education and clinical practice. DOCUMENTATION. In October 2001, team members performed medical record chart audits to analyze content and the flow of information for six measurement standards. The forms not only lacked the required information, but also failed to support a continuum of care or link the point of care from each surgical area to the next. The following changes were implemented. The preoperative pain assessment ONA ICT PLANNINGAND IMPLEMENTATION record (Table 3) was enhanced to ensure After agreeing on the key foci for the that health care providers documented project, team members began develop- an acceptable comfort function goal as ing action plans to more fully analyze agreed upon by the patient. Comfort and develop strategies for implement- function goals help health care proing improved processes, resulting in viders individualize a pain manageimproved patient outcomes. The PI ment plan for each patient and should 0

NO 3

Figure 1 Chart audit results (ie, percentage scores) from Virginia Baptist Hospital in October 2001 and January 2003.

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Figure 2 Chart audit results (ie, percentage scores) from Lynchburg General Hospital i n October 2001 and January 2003.

386

be specific to the pain scale used. The form also was revised to improve documentation of education provided to patients about specific pain scales and overall pain management. The perioperative nursing records specific to local surgery that may include conscious sedation were updated to include documentation for continued pain management assessment. Additionally, the sedation and analgesia form used in other areas throughout the facility, such as interventional radiology for invasive procedures, was updated to include pain assessment. The postanesthesia care record for phase I recovery was revised to include documentation of pain management and assessments of patients in the PACU. Appropriate scales were incorporated in the form based on recommendations from the Centra Health pain council and current literature reviews. For example, the adult numeric (ie, zero to lo), faces pain rating, FLACC (ie, preverbal patient pain scale that evaluates face, legs, activity, cry, consolability) and sedation scales are used as deemed appropriate for each

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patient.*’ These scales have been incorporated into documentation forms and the teaching materials and tools provided. These scales also help patients and staff members determine the comfort function goal most appropriate for each patient. The form now identifies pain management intervention strategies and provides a final reassessment of patients’ pain ratings before discharge from the unit. Patients’ predetermined acceptable comfort function goal is considered when assessing and managing pain postoperatively. The patients’ comfort function goals are communicated throughout the continuum of care. In addition, the two PACUs discussed setup and initiation of patient-controlled analgesia (PCA) pumps in recovery before patient transport. The LGH campus was employing this practice; however, the VBH campus was setting up the pump but not delivering the initial bolus until after discharge and transport from the PACU. To establish the same standard of care and best practice, both campuses now setup and deliver the initial bolus in the PACU before transport.

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TABLE1

Number of Patients Receiving Pain Medication (x 100) 2001-3rd quarter

20014th 2002-1st quarter quarter

2002-2nd quarter

2002-3rd 20024th quarter quarter

Virginia Baptist Hospital Hydrocodone Ketorolac Meperidine Morphine Oxycodone Propoxyphene

11.0 36.4 46.5 16.9 16.5 14.0

13.4 40.7 31.8 17.0 23.3 11.6

21.7 48.4 20.8 19.9 29.8 8.7

20.2 41.8 20.2 22.3 30.9 4.2

19.9 50.3 13.5 13.8 36.4 3.6

29.4 44.4 9.7 15.1 40.6 2.1

Lynchburg General Hospital Hydrocodone Ketorolac Meperidine Morphine Oxycodone Propoxyphene

56.8 25.9 14.1 12.0 22.9 14.7

52.7 26.2 11.4 12.1 31.5 13.4

67.5 37.3 17.9 17.5 53.8 9.7

31.4 24.5 8.9 18.5 38.2 8.2

55.028.8 10.4 12.8 28.4 7.6

40.3 23.6 10.0 15.1 35.9 3.9

TABLE2

Number of Patients Receiving Antiemetics (x 100) 2001-3rd quarter

20014th quarter

2002-1st quarter

2002-2nd quarter

Virginia Baptist Hospital Droperidol Metoclopramide Ondansentron Promethazine

34.3 2.8 71.8 16.0

32.8 3.3 79.9 16.4

20.6 3.7 77.6 17.4

9.7 9.2 80.5 24.4

Lynchburg General Hospital Droperidol Metoclopramide Ondansentron Promethazine

0.0 11.8 15.5 20.2

0.0 13.0 17.0 18.9

0.0 11.6 28.8 25.2

0.0 24.1 27.4 13.9

~

The postoperative nursing record for phase 11 recovery also wasrevised to include intervention of pain management, sedation scales, and final assessment of patients’ pain ratings before discharge from the hospital. Health care providers strive to achieve, at a minimum, patients’ predetermined comfort function goals and pain ratings. PATIENTAND FAMILY MEMBER EDUCATION. The

chart audits performed in October 2001 revealed a lack of evidence of patient and family member education in regard to pain management and pain scales. The PI team evaluated the results of this audit, which reflected inadequate current educational materials and processes. Team members determined that current education practices needed to be enhanced, so AORN JOURNAL

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TABLE3

Surgical Services Preoperative Pain Assessment Record Does the patient have any pain? Yes, continue with complete assessment No, complete section A #2 comfort function goal and section B below

A. Pain assessment 1. Have the patient describe location of pain and indicate on drawing.

2. Have the patient describe intensity of pain using pain scale in section B #3. Present score: Comfort function goal score:

3. Have the patient describe quality of pain using his or her own descriptive words. ache burn dull prick pull sharp throb other: 4. Have the patient describe the onset, duration, and any variation of the pain. When does the pain occur? How long has the patient had it? How long does it last? What causes or increases the pain? activity body positions lack of sleep

stress

5. Have the patient describe the effects of the pain. altered or decreased physical activity insomnia nausea social or emotional other: 6. Have the patient describe what relieves the pain? medication positioning rest other:

activity cold packs

hot packs

E. Education and pain management plan 1. The patient and family members have been educated on pain management plan. yes no

2. Do the patient or family members have any concerns that might keep the patient from requesting pain medication if needed? none identified fear of addiction adverse reactions past experience (ie, personal, with family members) comment: 3. Check appropriate scale used 0 to 10 scale faces (ie, 0 to 10 scale) faces, legs, activity, crying, and consolability (FLACC) (ie, children, age c 1 to seven) other: 4. Assessment Preoperativevisit Day of procedure: If the patient had a preoperative visit: no change noted comment

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(signature) (date) (signature) (date) change noted, and if so, please

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In addition to assessment and determination of the comfort function goal, preoperative nurse educators and anesthesia care providers considered anxiety levels in discussions with patients. they revised all major preoperative teaching booklets and incorporated a separatepage dedicated to comfort and pain management instructions. A pamphlet titled Patient’s Guide: Instructions for Comfort 6 Pain Management then was developed. This pamphlet included patient information on pain control techniques, including medications, use of cold and warm packs, diversions and distractions, elevation of extremity, and deep breathing with peaceful imaging. This tool was placed in all patient rooms in both surgery centers and was included in the patient teaching process in both preoperative education and testing centers. The PI team has established a future goal to have this pamphlet available for patients in surgeons’ offices. In addition to assessment and determination of the comfort function goal, preoperative nurse educators and anesthesia care providers considered anxiety levels in discussions with patients. Risk factors and special needs are individually addressed during the preoperative interview process. For example, before the efforts of the PI team, diazepam was widely given preoperatively to a majority of patients. A change has resulted in diazepam now being administeredbased on individual need. Chart audits were performed again in January 2003. Overall, there has been a signhcant increase in documentation compliance relating to the six standards of measurement concerning pain assessment. STAFF MEMBER EDUCATOI N. Staff members from each area specifically identified their own educational needs. This input was critical and yielded greater support and success and better outcomes. Staff members were educated about each redesigned form to ensure that a link existed between each area in surgical services to enhance the pain manage-

ment continuum of care. Staff members completed mandatory education programs on pain management to increase their knowledge and competency levels. This was accomplished through various methods (eg, CD-ROM programs, videotapes, bulletin boards, staff meetings). The surgical services division of Centra Health elected to make January a pain management awareness month annually. The intent is to heighten awareness and stay abreast of changes in clinical practices regarding pain management. PHYSICIAN STANDING ORDERS AND PROTOCOLS.

After reviewing current clinical practices at both hospitals, team members strongly recommended developing postoperative phase I and II standing orders and protocols to better manage patients’ pain and comfort levels (Tables 4 and 5). The goal was to have both anesthesia groups responsible for the management of patients’ comfort and pain postoperatively to the point of discharge from the hospital. Each medical record would contain a preprinted standing order form that the anesthesia care providers could access easily. Team members consulted with key champions from each anesthesia group. The outcome of these discussions was successful, and standardized anesthesia orders were formulated and approved between the two hospitals. The orders were designed to allow anesthesia care providers to select medications from a preformatted standing order set appropriate to each patient based on procedure, medical history, anesthesia administered, and other medications given before arrival in the PACU. The standing orders also were expanded to include additional orders frequently required postoperatively (eg, oxygen, glucometers). This has been a great success and has affected response time to pain management and care of AORN JOURNAL

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TABLE4

Postoperative Phase I Standing Orders and Protocols Orders are active only when the form is signed and dated and individual orders are selected by initialing in front of the order. Administer one of the followinq medications as needed for (PRN) pain. ' Fentanyl pg IV every (9) 3 to 5 min up to a maximum of Ketorolac 15 or 30 mg IV if not given in OR. mg N q 5 min up to a maximum of Morphine mg. Administer one of the followinq medications PRN respiratory problems. Albuterol2.5 mp in 3 mL unit dose via nebulizer; may- repeat - x 1 dose. Dexamethasone- 4 or 8 mg N, pm x 1dose. Administer one of the following medications for systolic blood pressure (BP) >diastolic BP r ,or mean arterial pressure > Hydralazine 5 mc or 10 mg N initial dose; repeat with 5 mg, then 10 mg, if needed, every 5 min up to mg total, if heart rate (HR) remains > . Labatalol IV initial dose; repeat with 5 mg, then 10 mg, if needed; may repeat up to mg total, if HR remains > .

.

Administer oxygen as needed. L per minute via nasal cannula or facemask PRN to maintain oxygen saturation > %.

- Oxygen-

Measure blood suqar level with qlucometer while patient is in postanesthesia care unit (PACU). Insulin orders: If insulin is administered, repeat glucometer in 1 hour. Perform the following labo.r$o-ry

tests in PACU.

Perform the followinq radiographic examinations in PACU. Chest x-ray for central line placement Discharge when appropriate. Discharge from PACU per PACU discharge criteria. Discharge from PACU < 45 min if criteria are met.

Physician's signature:

Date -

patients postoperatively. Medications physicians' lounges. The form disare delivered in a more timely manner, played information regarding Centra and nurses are better able to control Health's policy for pain management patients' pain so that comfort function and changes in nursing documentation, including the approved pain scales to goals are attained. be used consistently throughout the PHWCIAN EDUCATION AND CLINICAL PRACTICE. The PI team also was interested in organization. Additionally, data was assisting and supporting physician edu- shared specific to the medication utication regarding pain management. An lization study. Data from the study educational trifold form was construct- included an analysis of the use of opied and placed in both facilities' OR oids, nonopioids, and antiemetics by

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TABLE5

Postoperative Phase I1 Standing Orders and Protocols Orders are active only when the form b signed and dated and individual orders are selected by initialing in front of the order. Administer one of the followinq medications as needed for (PRN) pain. Acetaminophen 325 mg to 650 mg or ibuprofen 200 mg to 400 mg by mouth (PO) every (9) 4 hours. Acetaminophen300 mg with codeine 30 mg, 1to 2 tablets PO q 4 hrs. Acetaminophenelixir or acetaminophen elixir 120 mg with codeine 12 mg PO dose according to weight for pediatric patients (1mg per kg); may repeat x 1. Hydrocodone 5 mg with acetaminophen 500 mg PO q 4 hrs. Morphine sulfate 2 mg IV q 5 to 10 min, for total maximum 10 mg to 15 mg. Oxycodone 5 mg with acetaminophen 325 mg PO; may repeat x 1 dose after 30 min if no relief. Rminister one of the following medications PRN nausea or vomitinq. DroperidolO.625 mg to 1.25 mg IV; may repeat x 1dose. Metoclopramide 10 mg IV; may repeat x 1 dose. Ondansetron 4 mg IV x 1 dose. Promethazine mg IV or intramuscular x 1 dose. AaminisGr-oiy~nas needed. Oxygen ___ L per minute via nasal cannula or facemask PRN to maintain oxygen saturation > %.

Mlsi~oifiiigar level with qlucometer while patient m o s t a n e s t h e s i a care unit. Insulin orders: If insulin is administered, repeat glucometer in 1hour.

Discharge when appropriate. Discharge from surgery center per discharge criteria. Discharge from surgery center in < 45 minutes if criteria are met.

Physician’s signature:

surgeons and anesthesia care providers. Both facilities demonstrated a change in clinical practice as a result of the efforts of PI team members to educate physicians and staff members about pain management issues. To enhance the efforts of team members, the consulting clinical pharmacist attended meetings in the surgery department to provide information on current research and recommended practice. Nursing staff members began to encourage surgeons and anesthesia care providers to minimize use of meperidine and propoxyphene as a result of the research and recommendations of the pharmacp (Table 6).Additionally, the newly developed postop-

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.~

Date

erative standing order sets did not include meperidine as an option at the recommendation of the pharmacy and therapeutic c~rnmittee.~ This forced physicians who wanted to use meperidine to write an order for individual patients or select an alternative medication listed on the order set. Data review following the efforts of the team members reflected a decrease in the use of meperidine and propoxyphene from the third quarter of 2001 through the fourth quarter of 2002. Physicians and anesthesia care providers at VBH demonstrated an increase in the use of hydrocodone and oxycodone with a fluctuation in the use of morphine from the third quarter of

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TABLE6

Propoxyphene-N with Acetaminophen Dosing Alternatives D-ge (in mg)

N d r

of tablets

Dosing interval in h o w

325

2

4 to 6

m/30 325

1 or2

4

2

4 to 6

Aspirin with butalbital and caffeine

325/50/40

lor2

4

Hydrocodone with acetaminophen Ibuprofen

5/500 200 to 400

lor2

4 to 6

lor2

4to6

Oral medication Acetaminophen Acetaminophen with codeine Aspirin

The purpose of the chart is to give care proaidets a choice ofpain medications other than using propoxyphene-N with acetaminophen.These medications am listed dphabetiuzlly,are not ranked or all inclusive, and are safer and more effective than propoxyphene-hlwith acetaminophen.

2001 through the fourth quarter of 2002. Physicians and anesthesia care providers at LGH demonstrated an increase in the use of morphine and oxycodone during the same time period with a fluctuation in use of hydrocodone. Overall, there has been a steady decrease in the use of meperidine and propoxyphene from the third quarter 2001 through the fourth quarter 2002 at both facilities. Team members also wanted to decrease use of promethazine and increase use of ondansetron for the treatment of nausea as recommended by the pharmacy and therapeutic committee. Results of the medication utilization study reflect increased use of ondansetron; however, only care providers practicing at LGH decreased use of promethazine, so focus continues to be directed toward practice improvements in this area. In addition, PI team members discussed the need for an equianalgesic reference chart to further encourage physicians to consider practice changes. Team members recommended developing an equianalgesicchart in an effort to educate and encourage physicians and nurses to consider alternatives for pain management. A clinical pharmacist at Centra Health facilitated creating

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a laminated mini-equianalgesic chart (Table 7). This chart now is placed in strategic locations, such as physician dictation stations, physician lounges, nursing stations, and medication rooms. Some physicians have requested a personal copy. Team members have received positive feedback from surgeons and anesthesia care providers regarding several of the team’s initiatives. For example, the mini-equianalgesic chart and the new postoperative standing order sets now are used frequently. Some physicians now are noting patients’ pain levels in their medical records or asking nurses what patients’ pain levels are before ordering medication.

OUTCOME SUMMARY Many goals were achieved, as is demonstrated by positive measurable outcomes. Success was the direct result of collaboration between two hospitals to improve and standardize care. Nursing staff members, anesthesia care providers, and surgeons all were included in this collaboration. As reflected in the chart audit, documentation has improved sigruficantly,demonstrating 92% to 100% improvement in all elements measured as of October 2002 with only one exception. The issue

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TABLE7

Narcotic Analgesics: Equianalgesic Dosing Cornparkon Medicatioiis in each column are equivalent doses (eg, butorphanol3 mg every f q l 3 to 4 hrs is equal tofentaiiyl 0.15 wzg q 4 to 6 hours).

IV medications Butorphanol 1mgq 3to4hrs

1.5 mg q 3to4hrs

2mg q 3to4hrs

3mg 9 3to4hrs

3.5 mg q 3to4hrs

4mg 9 3 to 4 hrs

80 mg q 4to6hrs

120 mg q 4 to 6 hrs

Not recommended

Not recommended

Not recommended

0.1 mg q 4to6hrs

0.1 mg q 4to6hrs

0.15 mg q 4to6hrs

0.15 mg q 4to6hrs

0.2 mg q 4to6hrs

0.5 mg q 1t02hrs Mependine

1mgq 1 to2hrs

1.5 mg q 1 t02hrs

2mg 9 1 to2hrs

2.5 mg q 1 t02hrs

3% 9 1t02hrs

25 mg 9 3 to 4 hrs

50mg 9 3to4hrs

75 mg 9 3 to 4 hrs

1Wmg 9 3to4hrs

125 mg q 3to4hrs

150 mg q 3to4hrs

Codeine 40 mg every 4to6hrs Fentanyl 0.05 mg q 4to6hrs

Rorphine sulfate (MS) 3mgq 2to4hrs Nalbuphine

7mgq 2to4hrs

10mg 9 2to4hrs

13 mg 9 2to4hrs

17 mg 9 2to4hrs

20mg 9 2to4hrs

3mgq 3 to 6 hrs

7% q 3to6hrs

10mg 9 3 to 6 hrs

13 mg 9 3to6hrs

17mg 9 3to6hrs

20ma 9 3to6hrs

30mg q 6 hrs

30mgq 4 hrs

30mgq 3to4hrs

30 mg 9 2to3hrs

30mgq 2hrs

1mgq 6hrs

1mgq 4 hrs

2mg 9 6 hrs

2mg 9 4to6hrs

2% q 4 hrs

15 mg bid

20 mg bid

Not recommended

Not recommended

15 mg bid

20 mg bid

30 mg bid

30 mg bid

10 mg bid

20 mg bid

20 mg bid

30 mg bid

ltabq 6 hrs

2 tabs q 6hrs

2 tabs q 6 hrs

2 tabs q 6 hrs

Oral medications Codeine 15 mg 9 6 hrs

Hydromorphone No equivalent

Methadone 5 mg two 10 mg bid times q day (bid) M S F n d e d release No No equivalent equivalent Dxycodone No equivalent

10 mg bid

bxycodone controlled-release 1 tab q 1 tabq 6 hrs 6 hrs

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of ensuring documentation of patients’ pain rating in the PACU using appropriate scales at one facility is being addressed. Reevaluation with chart audits is scheduled to occur in 2003. The continuum of care delivered has improved as has communication between the facilities, departments, and health care team members, Staff members which has enhanced pain management for surgical have supported patients. Staff members have been extremely supthe changes as portive of the changes implemented. Their eathey have been gerness to learn and build a strong knowledge base imp1emented. for pain management and related pharmaceutical They are eager issues was reflected in staff members’ complito learn and ance with attending pain education build a strong management sessions. Patient and fammember educational knowledge base ily material and tool enhancements also have for pain been fully implemented. Team members plan to management. monitor patient satisfaction survey scores as a measure of success for many of the strategies implemented. For example,patients have the opportunity to rate facilities on how well they feel their pain was controlled. Physician education also has been critical in the success of team members’ goals. Staff members at both hospitals have become stronger patient advocates and encourage anesthesia care providers and surgeons to provide orders in keeping with recommendations from the pharmacy. Both anesthesia groups were educated on and requested to use the new physician standing orders and protocols form. The orders now are used on 100%of the records of patients rout-

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ing through the PACU at VBH and 96% of patient records at LCH. The orders have facilitated staff members’ ability to intervene and =pond in a more timely manner to patients’ requests and needs for pain management in the PACU and the surgery centers. An additional benefit gained was the collaboration of the separate anesthesia groups from each hospital in support of a PI team. This joint effort may open doors to future improvement efforts. Team members will continue to meet on a quarterly basis to monitor and measure future outcomes. The surgical services division has identified this team as one of the most successful regarding process for PI efforts. In addition, the Centra Health pain council is using the PI team as the model to help start initiatives in other service areas. Members of the PI team identified and chartered a course to improve pain management for surgical patients. The surgical services division realized that successful pain management was more than just complying with JCAHOs’ standards for pain management. Though the Commission’s standards are required, surgical services staff members acted on the desire to do the right thing and make a sigruficant difference in patient care delivery and outcomes.

+

Sharon W.Chavis, RN, BSN, is the surgical services nurse manager at Viiginia Baptist Hospital, Centra Health, Lynchburg, Va.

Linda H.Duncan,RN, BSN, CNOR, is the OR education coordinator at Viiginia Baptist Hospital Centra Health, Lynchburg, Va. NOTES 1. “Pain assessment,” in 2000 Com-

prehensive Accreditation Manual or Hospitals (Oakbrook Terrace, d J o i n t

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Commission on Accreditation of Healthcare Organizations, 1999) RI14-14a. 2. M K Bader et al, "Usin a FOCUS-PDCA uality improvement mo el for applying severe traumatic brain injury guidelines to practice: Process and outcomes," The Online Journal of Knowledge Synthesis for Nursing, The Honor Society of Nursing International, ht t ://www.stti.iupui.edu /library/ojksn/cc-a!ckhtml (accessed 3 July 2003). 3. M McCaffe C Pasero, Pain: Clinical Manual, seconTed (St Louis: Mosby, Inc, 1999). 4. "18 Multi-language pain assessment scales," Partners Against Pain, h t t p : / / m .partnersagainstpain.com/html/assess/scales/asscale2.htm (accessed 3 July 2003).

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5. D Won S E Perry, M J Hockenbe Maternal (%ild Nursing Care, second e (St Louis: Mosb 2002), 1088. 6.S I Merlceret al, "The FLACC: A behavioral scale for scorin postoperative pain in young children," Pefktric Nursing 23 (May/June 1997) 293-297. 7. J R Svirbely, M G Sriram,"Sedation scales and scores," The Medical Al orithms Project, h t t p : / ~ . m d a l . o r g / a ~ i o c s / ~ c s ~ c h 3 1 /doc-ch31.03.html#A32.03.05(accessed 3 July 2003). 8. "Recommendations from pharmacy," Physicians Newsletter (L chburg, Va: Centra Health, Se terncr 2002). 9. "Pharmacy an thera eutics committee Centra Health, minutes" (L chburg, May 6,2002y

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Continuous Pulse Oximetry Monitoring May Benefit Patients ontinuous pulse oximetry monitoring may reduce costs by nearly 50% for patients who undergo cardiothoracic surgery and are readmitted t o the intensive care unit (ICU) from a general care area, according to a June, 4, 2003, news release from Nellcor, a division of Tyco Healthcare. Researchers from the University of Pennsylvania conducted a study of 1,000 patients who randomly were selected t o receive continuous pulse oximetry monitoring or standard intermittent pulse oximetry monitoring. Complete data was available for 989 of the participants. Of these patients, 85% underwent cardiothoracic surgery, and most were admitted t o the general care floor after a postoperative stay i n the ICU. Costs were determined 0 a t discharge t o a non-ICU location (eg, home), 0 a t transfer t o a higher acuity area (eg, the ICU), and 0 from entry through discharge from the ICU. For patients with ICU stays, costs were compared between patients who returned t o the general care floor (ie, ICU survivors) and those who were not returned t o the general care floor (ie, ICU nonsurvivors). For patients who were not transferred t o the ICU, costs for the study were comparable for the continuously monitored and intermittently monitored groups. Costs for patients readmitted t o the

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ICU, however, were lower for the group that received continuous monitoring. Costs for ICU survivors were $29,400 for the continuously monitored group compared to $48,600 for the intermittently monitored group. Costs for nonsurvivors were $51,400 for the continuously monitored group compared t o $82,100 for the intermittently monitored group. I n this study, fewer patients who received continuous pulse oximetry monitoring were transferred t o the ICU for respiratory diagnoses. This may predict fewer ventilator days and other savings that could account for the cost reduction for continuously monitored patients transferred t o the ICU. The researchers concluded that continuous pulse oximetry monitoring of patients who undergo cardiothoracic surgery after admission t o a general care area from the OR, postanesthesia care unit, or ICU is associated with reduced cost. This potential cost reduction i s seen i n patients who are readmitted t o higher acuity areas, especially the ICU. The researchers noted, however, that cost savings were not offset by increased costs associated with continuous pulse oximetry monitoring i n large numbers of patients. Study Finds Continuous Pulse Oximetly Monitoring Reduces Patient Care Costs (news release, Pleasunton, Calif: Nellcor, June 4, 2003).

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