Pain management, done correctly, can save money and stop suffering
Proper pain assessment will lead to more efficient use of resources
Two experts in pain management have some financial advice for hospice managers and hospital administrators: Understand the proper techniques for pain management, and you could save thousands of dollars every year at your facilities.
Saving money was not the reason the two came up with their techniques. Cutting back on the misery of suffering patients was always at the head of their list. The savings came as a common-sense by-product of their methods — and not an unwelcome one at that.
"You can’t afford to not train your nurses," cautioned Maureen Carling, RN, SCM, NDN, HV, pain management specialist and educator with Chatsworth Pain and Symptom Management in Williamsburg, VA. She and Brenda Clarkson, RN, DN, CRNH, a senior consultant with Hospice Solutions, Richmond, VA, shared their views with a group of about 50 colleagues recently at the National Association for Home Care’s annual meeting in San Diego.
By training nurses in ways to properly manage pain, which both Carling and Clarkson agreed is a neglected skill that is often obscured by a world of powerful drugs, suffering is relieved and hospice and hospital operations become more efficiently run. The first step to finding the proper path is by returning to a fundamental of pain management that Carling said has been forgotten: Ask lots of questions and don’t settle for easy answers.
According to Carling, the most-favored way of determining how much pain a patient has is to present it on a scale, such as, "On a scale of zero to 10, how much pain are you in?" The dosage of painkilling drugs that are administered is then based on the answer. But Carling said the zero-to-10 scale, though valid, is only part of an overall pain assessment that should be performed.
Other assessments include asking the patient about the duration of the pain and whether the pain level varies. Is it a burning pain? A shooting, stabbing pain? A steady ache? A pulling, tightening pain? Is it pain from a cramp? Is the pain worsened by movement? It’s only when the pain has been examined from many angles, Carling emphasized, that the road to dulling it can be determined.
A compounded mistake
She related an anecdote of a time when she visited a patient whose pain could not be dulled with morphine. Doctors and nurses were stumped as to how to manage it. Carling said she examined the patient, asked questions, and found the pain was a result of cramping. The prescribed treatment had been morphine, which was ineffective because pain from cramping does not respond to morphine.
"Mistakes can be compounded. I see it all the time," she said. "You need to get a very clear picture of the pain. . . . Instead of asking the pain level, ask, Where is it? What does it feel like?’ Most patients have more than one pain. Then do a rating scale for each pain."
Determining the type of pain, whether it is soft tissue pain, neuropathic pain, or bone pain, should point the way to the proper medication. Some pains do not respond to opiates, for instance. As an example, Carling said a nurse wouldn’t offer an antacid to someone with a headache. So, she urged offering the right medicine for the right pain.
"If a pain reliever is ineffective, then discontinue using it," she said. "You’ll save your hospice thousands. Also, look at the length of time that it lasts. Perhaps the amount should be raised or lowered."
Carling has come up with an algorithm that includes a chart of the human body. She said the chart is useful in determining the proper pain medication to prescribe. The chart allows nurses to write down, in detail, the patients’ responses to questions about their pain. Nurses can map out the location of the patient’s pain on the chart, then elaborate on the markings with detailed observations. It’s a pain assessment tool that Carling said physicians seem to like because it offers much more information than the response to the usual zero-to-10 scale.
"Don’t just chart the pain. Do something about it," Carling advised.
The equations
Some of the sample questions from the competency test show how in-depth questions about pain can become. For instance:
1. Which types of pain are only semi-responsive to opioids?
A. Nerve compression
B. Colic
C. Neuropathic
D. Bone
E. Pleuritic
F. Soft tissue
G. Muscle spasm
H. Visceral
Then choose one of the following responses:
a) a + c + f
b) d + f + h
c) a + d + e
d) b + d + g
e) a + e + h
The use of combination answers from the algorithm is also shown in this question:
2. Which pains are opioid-resistant?
A. Pleuritic
B. Colic
C. Bone
D. Nerve compression
E. Soft tissue
F. Muscle spasm
G. Neuropathic
H. Visceral
Then choose one of the following responses:
a) a + c + d
b) b + f + g
c) c + d + h
e) b + d + e
Both questions should lead nurses and doctors to a better determination of pain and its management. The better the pain management, Carling said, the less morphine used and fewer pumps. Which all leads, she added, to less money being spent, fewer drugs being wasted, and pain medication that is targeted to the proper pain.
For the pain management novice, Carlson has devised a four-hour introduction to pain management, which includes the use of the chart, ways to record the assessment data, and how to determine the path to the proper pain medication.
Clarkson is a firm believer in teaching people how to interpret the data and developing a plan of care to meeting the patient’s needs. Much of that interpretation involves using the proper standards and regulations that she believes should guide pain management.
"Every patient should get the same level of attention and we’re not always seeing that," she said. In educating nurses, Clarkson said she is seeing less hands-on learning, much to the detriment of the patient.
"We have to teach people how to interpret data and develop a plan of care to meet the patients’ needs," she added. "Then you need to reassess and make another plan, if necessary."
Adherence brings results
The orientation/education standards that Clarkson recommends are from the Health Care Financing Administration (418.52 and 418.64), the Joint Commission on Accreditation of Healthcare Organizations (LD6, 6.2), and the National Hospice Organization (GB6). She also recommends a regimen of continued education training.
Clarkson said adherence to those regulations result in a nurse who is well-educated and proud of what they do. When you get that combination, she added, then morale goes up and positive results rise to the surface.
Carling added that monitoring of pain is another important assessment tool and that is an area where pain management often falls short. Check on the patient during weekends and nights. "Tell them to call you if there’s a problem," she said. "Don’t have them wait until Monday."
Careful monitoring also leads to discovery of pain that nurses and often the patient was not aware of previously. "Low-grade pain is often hard to feel until a larger pain is gone," Carling observed.
Working the family
Another method of pain management Carling recommended does not come with a chart or a regulation — it involves working with the family of the patient. There needs to be good communication, she said, between the family, the patient, and those in pain management. To know exactly what is going on with patients who do not always communicate their pain properly to doctors and nurses, the family is key. The patient may be telling family members something different than what they tell their pain managers.
"Work with the matriarch because if you don’t, you’ll get nowhere," Carling advised.
Communication among the pain management team, which could include the hospice nurse, attending physician, medical director, and an ethics committee, is vital in making sure a patient receives the proper care in what could be the final days.
"This is who you have to have on your side," Carling said. "Go to them. It’s unethical to leave a patient in pain. A hospice is about quality of life, not a philosophy of death."
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