2-pronged approach improves pain recording
From 7.4% to 38.2% documentation
An intensive staff education program and a targeted revision of medical charting has enabled the pediatric ED at New York Presbyterian Hospital/Weill-Cornell Medical Center in New York City to boost pain score documentation from 7.4% before the intervention to 38.2% after its implementation.
While noting that "we expect everybody to have a pain assessment — it could be a zero," Shari Platt, MD, director of the pediatric ED, says her facility’s performance is relatively good in an area of emergency medicine that clearly needs improvement. "In the literature, I’ve seen nothing above 50%," she says.
Only 45% of children scored
This statistic squares with the findings of a 2005 presentation at the American Academy of Pediatrics National Conference and Exhibition by Amy Drendel, DO, MS, assistant professor of pediatrics, Emergency Medicine Section, Department of Pediatrics at the Medical College of Wisconsin, Milwaukee. Drendel reported that from 1997 to 2000, only 45% of children nationally were receiving a pain score in the ED, based on statistics from the Centers for Disease Control and Prevention’s National Hospital Ambulatory Medical Care Survey database.
A two-pronged effort
The NY Presbyterian/Weill-Cornell initiative, which grew out of a March 2004 project by Carl Caplan, MD, a fellow in the department of pediatrics, had two interrelated components. The first, involving staff education, included an introduction to the second component: a new way of charting.
For several years, the department had been using the Wong-Baker FACES Pain Scale,1 a popular assessment tool that asks children to evaluate their pain along a continuum of "smiley" faces showing different levels of pain. "The triage nurse was using it in her initial assessment, the scale was posted on the wall, and the score was documented in the nursing notes," Platt recalls. "Where it didn’t exist was in the physician notes, so we actually added the scale to the medical record."
Becoming more aware
Having the physicians documenting the pain scores is important, she explains, "because it makes you more aware of it, and I believe it makes you more conscious to go forward and treat the pain."
The education program involved a 10-minute computerized presentation, which was offered to individuals and small groups, notes Caplan. "Each of the physicians who were rotating through the ED during the study period was given an inservice," he reports. "This included a picture of the new chart design, an introduction to medical charting, as well as the scale and original instructions on using it."
Toward the end of the presentation, the residents and attendings were informed that traditionally pediatric pain has been undertreated and that they should pay specific attention to the children and their parents. "We also went over the different medications that might be used to treat pain, such as morphine and nonsteroidal anti-inflammatories like Tylenol," Caplan adds.
Following the presentations, charts were reviewed to see how often the physicians’ notes made any reference whatever to the pain score, and the aforementioned increases were noted.
Treatment unaffected?
Interestingly, Caplan’s study, also presented at the 2005 American Academy of Pediatrics National Conference and Exhibition, did not find any difference in treating pain, Platt says. However, the study looked only at pre- and post-treatment of pain in kids who had gotten scores of 6 or greater on a scale of 10, she says.
"At that point we were only looking at a small subset," says Platt, indicating that the scale is probably more valuable where lower levels of pain are involved, since children who are clearly in great pain naturally would be treated.
Still, says Caplan, the physicians’ performance improvement in documenting pain probably was an accurate reading of the impact of the scale for those patients. "During the time of the study, they were only aware of being inserviced on a new medical record and charting — not that their behavior was being studied," he notes.
Increasing awareness
Still, Platt is eager to see more improvement. "I think we need to increase our awareness of measuring pain and treating pain," she says. "It’s a big initiative in pediatric emergency medicine, and [the Joint Commission on Accreditation of Healthcare Organizations] requires pain assessment on everybody." The Joint Commission introduced pain standards in 2001, which included the requirement to conduct pain assessments.
"Using FACES is a great thing — it does help — but we need ongoing [continuing medical education]," Platt insists. "We have residents rotating through here, so every month we should re-emphasize how important pain scoring is. But in reality, the same person should go through [the inservice] on a regular basis."
Caplan agrees. "I think we need continuous presentations and medical education on a regular basis — and/or implementing some kind of lecture series or training in medical school or early on in residency," he says. "There’s really not a lot of formal training in most institutions on how to treat pain in the acute setting."
Reference
- Wong DL, Hockenberry-Eaton M, Wilson D, et al. Wong’s Essentials of Pediatric Nursing, 6th ed. St. Louis: Mosby; 2001.
Source
For more information on pediatric pain documentation, contact:
- Shari Platt, MD, Pediatric ED Director, New York Presbyterian Hospital/Weill-Cornell Medical Center, 525 E. 68th St., New York, NY 10021. Phone: (212) 746-5454. E-mail: [email protected].
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