Improve satisfaction through better pain control
Complaints need more attention from clinicians
Patients vary greatly in their tolerance for pain. But physicians and nurses at Bay Area Medical Center in Marinette, WI, recently lowered their tolerance with a comprehensive pain management program geared toward surgical care. The result: A significant rise in its patient satisfaction ranking with pain control.
With support from physicians, the hospital recorded significant improvement on six indicators, including more frequent assessment of pain, greater use of patient-controlled anesthesia, and reduced use of intramuscular pain medication. The pain control changes were based on guidelines published by the Agency for Health Care Policy and Research (AHCPR) in Rockville, MD.
Within a year, patient satisfaction with pain control rose from the 67th percentile to the 89th percentile in a national database of more than 400 hospitals.
The impetus for the project came from a collaborative of the Wisconsin Peer Review Organization, now called MediStar, in Madison.
"We wanted to benchmark ourselves against other hospitals," explains Grace Tousignant, RN, the hospital's risk manager/physician liaison and the coordinator of the pain project.
The comparison proved useful. Bay Area Medical Center began the project significantly below the mean of 15 other participating hospitals. After revising post-op flow sheets and patient education materials, educating physicians and nurses, and implementing new policies, the hospital rose to a level that was above-average in almost all areas. (See chart, p. 50.)
Bay Area Medical Center worked to alter attitudes toward pain and pain relief. During in-service training of medical staff, Tousignant cited one study that showed nurses consistently underestimated patient's pain.1
Instead of simply asking, "How is your pain?", nurses now ask patients to use a rating scale from 0 (no pain) to 10 (worst possible). Those numerical ratings are recorded either in nurses' notes or on a vital sign flow sheet.
Under the new policy, nurses respond to pain of 5 or more with more medication or a call to the physician. They must contact the physician for a possible change in medication if the patient reports pain of 5 or more during two assessments.
Perhaps more importantly, the project marked a new attitude toward patients' pain. For example, nurses were required to assess pain using the 0-10 pain scale every two hours for the first 24 hours after surgery. In fact, the nurses exceeded that, assessing pain on average 17.6 times in those 24 hours.
"[The project] changed the way we looked at pain altogether," says Linda Newbury, RN, director of the dialysis and ambulatory care unit. "It made us more aware of the patient's perception of pain.
When the peer review organization pulled 47 charts to follow up a year after the project began, they found an increase in pain assessment from 7.9 times in the first 24 hours to 17.6 times.
Tousignant began by seeking a project "champion" among the hospital's surgeons and assistance from anesthesiologist Anthony Mars, MD. Physician buy-in was critical to the program's success, she says.
She formed a multi-disciplinary quality improvement team that included physicians, nurses, and other members of the surgical staff. Bolstered by articles from the medical literature and the AHCPR guidelines, the committee's goal was "to improve the consistency of assessment and management of pain."
For baseline information, Tousignant pulled 50 charts of patients who had undergone partial excision of the large intestine, hysterectomy, and cholecystectomy.
The committee found that too often patients weren't receiving the most effective pain medication. For example, 82% of patients received intramuscular injections of Demerol (meperidine), although intravenous medication, such as morphine, typically provides more consistent relief, Tousignant says.
Mars and Tousignant visited surgery department meetings and spoke about the guidelines as well as anti-emetics that could be used to moderate side effects from narcotics such as morphine and make them more tolerable to patients.
"Education and communication is the most important part of this [project]," says Tousignant.
Pain management practices changed in same-day surgery, as well. Patients receive intravenous narcotics in the recovery room to dull the immediate pain and their first dose of oral medication before discharge from the ambulatory care unit, which is the secondary recovery area, Mars says.
"In [inpatient care], you always get a second, third, fourth, or fifth try at relieving their pain," says Mars. "In the ambulatory care unit, you have to address that pain on an immediate and long-term scale by exposure to the patient for a short period of time."
Nurses in the ambulatory care unit (the secondary recovery area for same-day surgery) assess pain when the patient arrives, a half-hour later, and before discharge. Again, the assessment is often much more frequent.
Patients learn about pain relief and the pain assessment scale through a brochure they receive preoperatively. "Patients were well-informed about what to expect," says Tousignant.
Based on the indicators and the patient satisfaction surveys, the project clearly succeeded in improving pain management. Yet it may have had other, less easily measured effects.
The hospital's rate of nosocomial pneumonia declined during the study period. There is no way to link that directly to the pain control, and other influences may have occurred, says Tousignant.
But Tousignant notes pain can cause patients to breath shallowly and remain confined to bed. "If we could control their [pain], patients would be up and walking and less likely to get pneumonia," she says.
The quality improvement committee has expanded its work to address obstetric patients in active labor, with the goal of increasing the use of intrathecal narcotics, which are administered in the back, and improving assessment of pain. With better pain control, Tousignant has recorded a decrease in Cesarean section rates among patients receiving intrathecal narcotics.
[Editor's note: For free copies of pain management guidelines, including a "Pain Control After Surgery" brochure for patients, contact the Agency for Health Care Policy and Research Publications Clearinghouse, P.O. Box 8547, Silver Spring, MD 20907. Telephone: (800) 358-9295.]
Reference
1. Seers, K. Perceptions of pain. Nursing Times 1987; 83:37-39.
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