Patient-centered philosophy at core of successful pain management program
How to access the ouch factor
(Editor’s note: In 1996, the American Nurses Credentialing Center in Washington, DC, recognized UC Davis Medical Center in Sacramento as a magnet nursing center of excellence. The pain management program was cited as one of the distinguishing activities that promotes quality of patient care services and development of successful nursing strategies.)
How can you implement an effective pain management program that increases patient satisfaction and improves outcomes? Create a patient-centered philosophy and integrate its basic tenets accompanied by practical tools throughout the health care system, says Sharon E. Melberg, RN, MPA, assistant director of hospital and clinics for general nursing services at UC Davis Medical Center in Sacramento, CA.
"We believe that patients are the true experts when it comes to their own pain. Therefore, we say that pain exists whenever and to the intensity that the patient says it does," she explains.
However, implementing a program based on such a philosophy wasn’t easy. In 1991, Melberg and a team of nurses and pharmacists, anesthesiologists, and physicians had to first identify educational, attitudinal, and systemic barriers and then work to remove them.
First, team members began the educational process by conducting a literature review for studies to support their assumptions that pain is "underreported and undermanaged."
"We found evidence that physicians were underprescribing, and nurses were undermedicating," Melberg says. "We also found how fear played a big factor in those decisions. There’s the fear of causing addiction, the fear of being labeled an overmedicator, and the fear of being questioned by a regulatory group."
To counter those fear factors with research-based information, the team then searched the literature for problems that occur when pain is not managed properly.
"We found that length of stay does increase and that more costs are incurred. For example, patients may return to the emergency room as they try to ease their pain."
Next, the team examined the attitudes of nurses and physicians by talking with them in informal and formal settings and asking such questions as, "What are your concerns about increasing the dose? Why do you use PRN dosing instead of around the clock?"
"We became aware that a significant number of health care professionals come from homes where substance abuse is an issue. This background may predispose us to fears and biases about prescribing medication for pain," Melberg explains.
The team also found that not all physicians have the triplicate prescription pad that is required for prescribing certain tightly controlled narcotic drugs such as morphine.
"Some resisted the hassle’ of obtaining and protecting triplicate pads; others felt if they become known as a physician who easily prescribes drugs, they would attract patients who were seeking drugs. They also worried they were at a greater risk of burglary," Melberg says. She notes this issue is still a problem, but she is seeing resistance melt as physicians see how much difference good pain management can make.
Nurses also had made faulty judgments based on their physical observation of the patient. "If patients don’t look’ like they are in great pain, they may be given a smaller amount of medication than someone who appears to be suffering and who acts like we think a suffering person should act," she says. "We heard such anecdotes as, Well, he was sitting and watching television, so I only gave him 50 mg instead of the 100."
In addition, physicians tended to order more meperidine because they perceived morphine as "the big gun" while meperidine was "not so bad." "But in fact, the right dose of each one has an equivalent effect. And certainly, each one is as open to abuse as the other," Melberg points out.
In fact, meperidine metabolizes into mormeperdine, a neurotoxin that may cause central nervous system damage and even seizures in elderly patients who can’t clear the medication as efficiently from their bodies. (For more on pain management in the elderly, see related story, p. 3)
System problems, the team found, added to issues related to attitudes and beliefs. For example, after requesting PRN medication, patients would have to wait as long as 20 minutes while someone found a nurse with the keys to unlock the narcotics box and sign out the medication. To compensate for this lag time, patients tended to ask for their medication early. "This contributed to nurses labeling the patient who frequently called for medications as having a low pain tolerance or even being a drug seeker," she says.
Going straight to the source
The team also conducted chart reviews which confirmed what they thought to be true, Melberg says.
To find out how well patients perceived their pain was managed during the hospital stay, the team worked with the marketing department to add the following question to its patient satisfaction survey: How satisfied were you with the way your pain was managed at UCDMC?
"We wanted to be able to gather [patient satisfaction] data and trend the improvements we made as we implemented the pain management program," Melberg says. (See chart of patient satisfaction results, p. 2.)
As the team began to draft their own philo-sophy of pain management, the Agency for Health Care Policy and Research released its guidelines.1
"This gave our program the stamp of authority because our philosophy was consistent with theirs. From that point on, our task became to implement the guidelines," says Melberg.
Contained in both guidelines were the following recommendations:
• Around the clock medication is superior to PRN dosage because the serum level of medi-cations is kept stable, controlling peaks and troughs.
• Non-invasive methods of administering medications are preferable to invasive ones, especially for pediatric patients. "Children will bear their pain rather than ask for a shot," she explains.
• Patient-controlled analgesics are effective if protocols and exclusionary criteria are followed. "Patients actually use less narcotics if they know they can deliver them as needed," Melberg explains.
• Outcomes improve if patients are kept as pain free as possible, tapering off medication as the condition improves. "For example, older patients who are in great pain from a rib fracture won’t cough or move or deep breathe, which makes them prone to developing pneumonia," Melberg says.
• Non-steroidal anti-inflammatory drugs and antidepressants are useful adjuncts to narcotics. "They allow better pain relief with lower doses of narcotics," she says.
• Patient must be informed about potential side effects of various analgesics such as nausea and constipation. "Side effects should be treated as soon as they are experienced," she says.
• Alternative therapies such as massage, positioning, relaxation techniques, application of heat or cold have their place in a well-rounded pain management program, she adds.
Use faces tool to identify pain
To discuss pain management from the patients’ perspective, the team developed an assessment tool in which nurses ask patients to rate their pain as 0, no pain at all, or 10, the worse pain they have ever experienced. "Yes, it is very subjective, but the goal was to be able to manage pain in that particular patient at that particular moment," says Melberg.
A similar assessment is used for pediatric patients. "A child points to one of five faces, ranging from a happy face to a face with tears streaming down," says Melberg. (See visual pain scale, p. 4.)
Also based on a 10-point scale was a corresponding audit form to monitor outcomes of a pain management program. In addition to noting patient name and demographic data, the form contained spaces for noting who was providing the information on pain management outcomes. "We wanted to know if it was a child or the parent. We also noted if an interpreter was assisting or if a nurse was questioning the patient in order to complete the form," she says. (See outcome monitor, pp. 5-6.)
If the score on the outcomes monitor was greater than 30, the team used the chart review tool to further investigate the causes of poor pain management. (See copy of chart review tool, pp. 7-8.)
Armed with survey results, literature review, and protocol guidelines, the team set out to disseminate the information throughout the hospital to address knowledge and attitudinal challenges. They began by presenting the information at each department’s grand rounds and by conducting pain management presentations during orientations for house staff. The team held discussions with the bioethics committee on pain management as a crucial component of right to life issues.
Pain management part of competencies
Finally, the team created the pain management portion of the nursing orientation along with a nursing competency checklist.
"We also modified the patient flow sheet to contain space for the pain scale score as well as changed the policy on using epidural catheters only in the intensive care units," she says.
The team also facilitated a move to a patented automated dispensing machine called Pyxis, manufactured by Cardinal Health.
"Nurses have an access code to the Pyxis now, so patients no longer have to wait for the nurse with the keys to be located," Melberg explains. The new system also provides a patient profile that offers quick and reliable information about pharmacologic pain management practices.
"We had to make changes at the knowledge, attitudes, and system level because we wanted to make pain management part of the culture here," says Melberg.
As a result of the team’s efforts, not only have patient satisfaction scores continued to increase, but the medical center was awarded a grant from Roxanne Laboratories in Ridgefield, CT, for a Center for Palliative Care Education. "We offer physicians, nurses, social workers, and staff formalized seminars in pain management as well as symptom control, psychosocial issues, and bioethics," she says.
Reference
1. AHCPR. Clinical practice guideline for acute pain management: operative or medical procedures and trauma. U.S. Government Printing Office, USDHHS, February 1992.
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