Reassess pain to comply with JCAHO standards
Avoid having dissatisfied ED patients
If you don't reassess a patient's pain levels periodically and document this reassessment, you're not in compliance with requirements from the Joint Commission on Accreditation of Healthcare Organizations.
"Management of patients' pain translates into higher patient satisfaction, efficiency, and quality care delivery," says Karen Rollo, RN, BSN, CEN, SANE-A, ED nurse at Christiana Care Health System in Newark, DE.
To improve reassessment of pain, do the following:
- Ensure consistent reassessment.
ED nurses at Christiana Care have been inserviced on the Joint Commission standards. "The timing of pain re-assessments should be based on when the intervention is expected to work," says Rollo. "For most medications, this would be approximately 15-30 minutes after administration."
Nurses are encouraged to strive to improve consistency of pain reassessment, with constructive feedback, e-mail reminders, and periodic inservices, she reports. For example, ED leadership recently sent an e-mail to nurses stating, "Congratulations to all staff on achieving 100% compliance with regard to assessing patient's pain in the ED for this month."
Rollo says, "If the staff feels that they are responsible for high scores and positive patient feedback and are made aware of this, they are much more motivated to be proactive in pain assessment and management."
- Ask patients for input.
When reassessing pain levels, nurses at Christiana Care's ED use a numerical pain scale and also ask the patient, "Have we managed your pain to your satisfaction?" "This elicits both objective and subjective responses," says Rollo.
- Use electronic systems.
At University of Tennessee Medical Center in Knoxville, an icon on the ED's tracking system [First Net, manufactured by Kansas City, MO-based Cerner Corp.] reminds nurses that the patient is due for another pain score assessment. A pain score is documented before and after administrating any pain medications, says Sheila Duncan, RN, EMT, ED nurse manager.
Once the nurse gives pain medication, she or he clicks on the pain reassessment icon so that the nurse or the technician working in that zone will have a reminder to recheck the effects of the medication on an hourly basis, she explains.
When nurses perform pain reassessment, they also check vital signs. "Any changes in the patient's condition can be identified, and pain assessment is part of that process," says Duncan. The process also has helped with the ED's patient satisfaction scores because patients feel they are being checked by the nurse at frequent intervals, adds Duncan. Satisfaction scores have increased from 69% into the low 80s, she reports.
- Audit charts for reassessments.
At Baylor Regional Medical Center at Plano (TX), charge nurses perform "pain audits" for 100% of patient charts one day every week, says Mark Sargent, RN, clinical manager of the ED. "We monitor or spot-check charts to ensure that if a pain medication was given, a reassessment was accomplished within one hour of administration," he says.
Nurses look specifically for initial pain assessment upon arrival to triage, intervention at triage or in treatment rooms, and reassessment within one hour. "The spot checks are performed by me on the off days between pain audits," Sargent says. He checks 10% of the charts per day, he says. "If the documentation is not in the chart, it becomes a coaching opportunity for me and the individual nurse," says Sargent.
Coaching for nurses
The ED's weekly compliance rate is posted on the communication board, along with a graph showing the percentages rates of individual nurses whose charts were audited. "If pain is not assessed in triage and reassessed after pain intervention within one hour, that nurse is coached by me," he says. Currently, the ED is averaging 97% compliance, he reports.
At Christiana Care, ED nurses on the hospital's performance improvement committee monitor charts to assess consistency of pain medication administration and reassessment, then update staff with the results and any opportunities for improvement, says Rollo. One previous problem was that pain was reassessed inconsistently when the ED was overcrowded. "Reassessing pain after the administration of medication may be delayed if the nurses are initiating a lot of care from the triage area," says Rollo.
During high-volume times, patient care technicians now help with retaking vital signs and obtaining pain scores, adds Rollo. "The technicians are not making an assessment, but if someone needs more pain medication or a reassessment, they bring it to the nurses' attention," she says.
Sources
For more information about pain reassessment in the ED, contact:
- Sheila Duncan, RN, BS, EMT, Nurse Manager, Emergency Department, University of Tennessee Medical Center, 1924 Alcoa Highway, Knoxville, TN 37920-6969. Telephone: (865) 544-8172. E-mail: [email protected].
- Karen Rollo, RN, BSN, CEN, SANE-A, Emergency Department, Christiana Care Health System, 4755 Ogletown-Stanton Road, Newark, DE 19718. Telephone: (302) 733-4799. E-mail: [email protected].
- Mark Sargent, RN, Clinical Manager, Emergency Department, Baylor Regional Medical Center at Plano, 4700 Alliance Blvd., Plano, TX 75093. Telephone: (469) 814-2529. E-mail: [email protected].
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