Pain care, documentation are improved by training
August 1, 1999 6 minutes read
Pain care, documentation are improved by training
Make sure nurses understand all pain definitions
Home care agencies and accreditation organizations are increasingly focusing on the pain management of home care patients. And at the same time, more surgery patients, who are experiencing pain, are being sent into home care after increasingly shorter hospital stays. It may be time to take a look at pain management as a separate performance improvement (PI) project.
Providence Home Health Care in Novi, MI, selected pain management as one of the two areas to focus on in the past year. The hospital-based agency, which serves southeastern Michigan, is one of the 50 agencies that for the past three years had been using the Outcome and Assessment Information Set (OASIS) tool as part of the national demonstration project.
Agency’s peers’ outcomes were better
The agency had slightly worse outcomes for pain management than had other agencies involved in the demonstration project, and the agency’s outcomes for pain management had fallen from the previous year, says Barbara Harlow, RN, acting director.
About 65% of Providence Home Health Care’s patients showed an improvement in pain, compared with about 68% nationally. During the previous year, 71.3% had improved. The results of the agency’s yearlong project won’t be known until its 1999 OASIS report is released later this summer.
The national data was risk-adjusted, so the comparison was fair. However, the performance improvement team soon learned that the decrease from the previous year was mostly due to a big change in the agency’s patient population. "We doubled the number of our short-term patients from a mastectomy program in which patients went to outpatient surgery and then we provided home care service for them," Harlow says.
The number of mastectomy surgery patients increased from 57 to 95. "We found that those patients didn’t score as well on pain control, and the reason was that it’s hard to measure an improvement in pain when you only see a patient for one or two visits," Harlow explains.
Still, the agency wanted to improve its pain management and documentation, so this is how the performance improvement program worked:
1. The PI team reviewed charts.
The team pulled charts of all patients who had poor pain management results according to the OASIS report.
Then the team developed a chart audit tool to use in identifying trends and problems with pain management and its documentation. The tool, which was revised several times, has 12 questions relating to OASIS and pain assessment. (See pain control audit tool, p. 99.)
2. The team identified trends and problems.
Using the tool, the team found some common and recurring problems.
"That’s how we found that a lot of the cases were mastectomy patients who had very short home care stays," Harlow says.
There also were other cancer patients whose pain did not improve, and another group included those who had a total joint replacement diagnosis.
Team members also found that most of the patients who had a longer length of stay showed improvement in the intensity of their pain. But they continued to score their pain as "daily, but not constantly" on discharge.
The PI team decided there was very little the agency could do to improve pain for surgical patients whom the staff visited once or twice.
But there was another problem that could be addressed. The agency’s nurses and therapists were using two different pain measurement scales, which led to inconsistency in the scoring and pain assessment.
Also, nurses were interpreting pain control methods inconsistently. For example, one OASIS question reads: "Intractable pain: Is patient experiencing pain that is not easily relieved, occurs at least daily, and affects the patient’s sleep, appetite, physical and emotional energy, concentration, personal relationships, emotions, or the ability or the desire to perform physical activity?" The question must be answered either "yes" or "no."
But the problem is some cases fell into a gray area. If a nurse had a patient who was on a morphine drip and didn’t have pain while on morphine, did that qualify as intractable pain that is not easily relieved? The team called the Denver-based Center for Health Services and Policy Research to find out the correct answer, and learned that if the pain was relieved by the morphine, then it did not count as intractable pain.
And team members decided the entire staff needed to learn a more consistent approach to pain control instruction and documentation.
3. Team members developed and imple-mented strategies to improve pain management.
The team selected a list of best practices to follow from current medical literature on pain management, and members developed pain control guidelines. (See pain control guidelines, p. 100.)
One of the first changes involved having the entire staff use one pain assessment scale that described pain from zero, meaning there was no pain, to 10, meaning the pain was the absolute worst. The agency’s therapists have already been using a zero to 10 scale, but the nurses had to be taught the new scale.
Then the team developed a pain control tracking tool, using ideas from other research material. The tool is a one-page sheet that staff can hand to patients. On the tool, patients will see a drawing of a thermometer that’s divided into 10 sections. Each section pertains to a number, and the chart gives word descriptions of five different pain measures, as follows:
• 2 = mild pain;
• 4 = moderate pain;
• 6 = severe pain;
• 8 = very severe pain;
• 10 = pain as bad as it could be.
Nurses or therapists show the tool to patients and have them point to where their pain would be on the thermometer scale. Then the staff member fills out a chart to the right of the thermometer diagram and records the date and time, the pain score before medication, medication and dose taken, and pain score after 30 to 60 minutes.
The chart also has room for pain control orders and the patient’s name.
"A lot of patients like the tool because it’s something concrete they can look at," Harlow says. "And it gives everyone a more consistent idea of where the patient’s pain level is."
The, the team changed the agency’s critical pathways for pain control to include these suggestions:
• Over-the-counter medications to titrate down to when able;
• Recommendation to call physician if pain level is four or greater after medication use;
• Relaxation and breathing exercises, and imagery used;
• Bowel regime with use of pain medications explained.
The team decided that only physical therapists should teach total joint patients about the timing of pain medications in relation to their exercise.
4. Staff members attended inservices and received more training.
Then the team implemented a major part of the pain management change by beginning new staff instruction on assessing, documenting, and managing pain. The inservices covered the agency’s lower-than-desired scores on pain management, why the PI team wanted the staff to focus on improving these, and the team’s plan to make these improvements.
"We have field staff members on the PI team, and we had the staff’s peers present the plan to them," Harlow says. "We try to have staff members — not management — do the presenting because it comes across a lot better from their peers."
It’s all relative
The inservices included general documentation guidance, showing staff how important it is that everyone interprets different OASIS questions the same way.
For example, instructors explained how different nurses were interpreting the OASIS question on intractable pain in different ways, and this would lead to inaccurate outcomes data. Besides the confusion over morphine drips, some nurses thought that a patient was experiencing intractable pain if the patient had to wake up in the middle of the night to take pain medication. But again the correct answer was that this does not signify intractable pain unless the medication gives the patient no relief from the pain.
"We told the staff that no matter what their personal opinion of what intractable pain is, this is the correct answer for this documentation, and they could add other details about the patient’s pain to other parts of the form," Harlow says.
Then the team had an oncology nurse teach the staff how to help patients control cancer pain.
Finally, staff members held special inservices on how to help a patient alleviate pain through alternative methods, such as relaxation and visualization techniques and holistic medicine.
One employee even developed a relaxation tape that nurses could give to patients to help them cope with their pain.
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