Use protocols to comply with new standards
In most EDs, there is tremendous variability as to how patients presenting with painful conditions are assessed and managed, stresses Emory Petrack, MD, MPH, chief of the division of pediatric emergency medicine at Rainbow Babies and Children’s Hospital in Cleveland. However, that inconsistency will have to change if your ED wants to comply with new standards published by the Oakbrook Terrace, IL-based Joint Commission on Accreditation of Healthcare Organizations (JCAHO), he warns.
"A major goal of the new standards is to ensure that a patient’s pain is appropriately and consistently addressed throughout the hospital," Petrack says.
Patricia Spurlock, RN, clinic administrator at Neurological Associates of Des Moines (IA) and formerly service line director of emergency services at Mercy Medical Center, also in Des Moines, says, "They will want to see how each organization meets the intent of the new standards."
By using protocols to include the assessment on the patient record and then using a numeric scale to measure the outcome, the intent is being met, Spurlock explains.
Here are benefits of using protocols to manage pain:
• Pain of every patient is assessed.
Most of your patients have pain, so you should assess pain universally, recommends Spurlock. "Assessment of pain should be completed at the same time vital signs are obtained."
By incorporating pain assessment in the standards of care, all patients are assessed for pain upon arrival, explains Spurlock. The management of the pain then will be driven by the patient’s response.
Through standardization of care, all ED nurses assess all patients, which provides a consistent approach to comply with JCAHO standards, Spurlock says. "If pain assessment is left to the individual nurse’s discretion, it reverts to the nurse’s perception, rather than the patient’s self-report of pain."
• "Invisible" pain is treated.
In the past, a nurse might ask if a patient had pain, but did nothing to intervene unless it was severe, impacted the management of the patient’s other needs, or affected compliance with treatment, notes Darlene Matsuoka, RN, BSN, CEN, CCRN, clinical nurse educator for the ED at Harborview Medical Center in Seattle. "A patient with serious orthopedic fractures might get adequate pain medication, but another patient with contusions might not," she says. "To be treated for pain, an injury would need to be visible.’"
Protocols can avoid nontreatment of pain by asking all patients to characterize and quantify pain, Matsuoka advises. "Even if the pain does not have a visible component, such as abdominal pain or headache, treatment is rarely excluded."
• Pain management is standardized with other departments.
Develop pain protocols using a multidisciplinary approach to allow all providers, nurses, and physicians to work in a united manner, says Paula Tanabe, RN, PhD, CCRN, advanced practice nurse for the ED at Northwestern Memorial Hospital and former clinical nurse specialist at Northwest Community Hospital in Chicago. Northwest Community Hospital was one of four EDs featured in JCAHO training tapes for surveyors on the new standards. (See protocols for ED EMLA cream and ED renal colic, inserted in this issue.)
• A baseline of the patient’s pain is established.
At Mercy Medical Center’s ED, a documentation tool was developed that is used primarily for the administration of conscious sedation, notes Spurlock. (See protocol for conscious sedation/deep sedation/pain management, p. 58.)
"While the management will change with each diagnosis and patient, the value is to establish a baseline to measure progress toward relief of pain," she says. "Uniform standards establish the framework that measuring pain is a component of patient assessment in all patients."
This creates a numeric baseline that is used to measure the outcome of pain treatments, as well as progression of pain during the ED visit, notes Spurlock. "In addition, the triage nurse uses the severity of pain as one criteria for placing a patient directly into a treatment room. Our criteria is a pain score of 7 or above."
• Nursing pain management is addressed.
Independent nursing functions should be included, such as the application of ice, immobilization, oxygen for patients with chest pain, and antipyretics, says Spurlock. "Some emergency physicians may approve the addition of medications such as opioids in the protocols, while other groups may not."
• Patient satisfaction is increased.
After pain management improvement initiatives were implemented at Mercy’s ED, patients responded with positive comments, reports Spurlock. "Perhaps of greater significance is the absence of patient complaints related to their pain not being taken care of."
A statement informing patients that they should expect their pain to be addressed is included in the patient brochure that is handed out at the triage desk and in the waiting room, says Spurlock.
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