Making a case for better management of back pain
Case managers incorporate federal guidelines
The December 1994 release of the Rockville, MD-based Agency for Health Care Policy and Research's (AHCPR) controversial guidelines for the evaluation and treatment of acute low back pain has left many case managers in a quandary as to how to best use them.
The guidelines have been considered controversial by some surgeons, in particular, because they recommend outpatient treatments over surgical options. Case managers using the guidelines have found them most beneficial to help manage patients who present for back surgery, to guide the care of back pain rehabilitation patients, and to use as background guidance for pain management programs.
Treating back pain is costly
Effective management of back pain patients also is an issue for inpatient case managers because treating low back pain is a costly venture for health care payers. For adults under age 45, low back pain accounts for 50% of disability and lost work time costs annually. And AHCPR researchers estimate that virtually every adult in the nation is affected by low back pain at some point in life.1
Regardless of how your facility decides to use the AHCPR guidelines, hospital case managers already using them agree the guidelines offer two benefits. First, the low back pain guidelines help provide a standard plan of care. Secondly, AHCPR's guidelines provide a solid building block for improving care of these patients.
That's what James A. Haley Veterans' Medical Center in Tampa, FL, discovered when incorporating the guidelines into its case management program. Although Haley's critical pathways and assessment plans for pain were in place two years before the AHCPR guidelines were released, pathway developers wanted to ensure that their program was falling in step with the new guidelines.
"We have used the [AHCPR] guidelines just to make sure our guidelines were fitting with theirs. We found that they were because we developed our pathways based on research that we found in the literature regarding pain management and we also had experts in pain management help us develop them," explains Pat Quigley, PhD, RN, rehabilitation clinical nurse specialist at the 600-bed facility.
Many of Haley's rehab patients are admitted for low back pain problems or have low back pain as a secondary problem, says Quigley.
In developing its own guidelines, the facility also reviewed back pain outcomes data from as far back as 1986. The facility's two pain pathways are for chronic and musculoskeletal back pain. The musculoskeletal path is used with patients who are still having medical work-ups and not yet ready for behavioral management. (To see how low back pain is incorporated into the daily plan of care, see the musculoskeletal path, p. 38.)
Path incorporates assessment
Rather than creating a separate assessment tool to monitor back pain as recommended by the AHCPR, Haley incorporated a back pain assessment mechanism into its critical pathway.
"The AHCPR guidelines deal a lot with assessments. Our pathways don't really address the assessment piece, but we do have an assessment mechanism in place. We use our critical pathways to identify patient needs and treatment. For example, if you look at the activity limits, covered in the activity aspects of the guidelines, a lot of that is already in our critical pathways.
"The activity guidelines listed in the pathway deal primarily with activities of daily living and mobility. So, we teach patients how they can go ahead and perform specific activities, as they were doing, and how to decrease some of the stress that might be on their backs, or stress that might be related to bad posture, or problems with balance. All of these activities, which AHCPR recommends, are already in our guidelines," Quigley explains.
To further ensure efficient care of low back pain patients, Haley employs a nurse practitioner who specifically assists in overseeing the medical management of these patients. The nurse practitioner helps manage the patients without the use of narcotics as much as possible. "She is a pain expert. We try not to use any kind of narcotic medication with our pain patients. Instead we try to work with nonsteroids," Quigley notes.
Guidelines helpful in diagnosis
Hospitals also can use the guidelines to help reduce variations in the way back pain patients are diagnosed and treated. For example, the guidelines can be used to guide physicians in determining when recommending an MRI is appropriate. They also include patient education tools.
Remember, however, that the guidelines are targeted to outpatient management, says Sharon Gates, MSN, RN, CS, a nurse practitioner on the musculoskeletal unit at Beth Israel Hospital in Boston.
"These guidelines are for acute low back pain. For example, the patient bends down tomorrow and can't get up because he or she has a sore back -- that's when the guidelines are used. They direct the provider to look for red flags to identify those things that would compromise the patient's recovery."
[Editor's note: For more information on the AHCPR guidelines or to order a copy of the acute low back pain guidelines, which cost $6 per copy, contact: AHCPR Publications Clearinghouse, P.O. Box 8547, Silver Spring, MD 20907. Telephone: (800) 358-9295.]
Reference
1. Bigos S, Bowyer O, Braen G. Acute Low Back Problems in Adults: Clinical Practice Guideline, Quick Reference Guide Number 14. Rockville, MD: Agency for Health Care Policy and Research; Pub. No. 95-0463; December 1994. *
You have reached your article limit for the month. Subscribe now to access this article plus other member-only content.
- Award-winning Medical Content
- Latest Advances & Development in Medicine
- Unbiased Content