Out of compliance with standards? You must assess and treat pain quicker
Surveyors will require consistency in your ED
Are you assessing, documenting, and managing pain for every patient you see in your ED? If not, you aren’t in compliance with new standards for pain management developed by the Oakbrook Terrace, IL-based Joint Commission on Accreditation of Healthcare Organizations (JCAHO).
"You need to get a copy of the standards and carefully review them, because your ED will be assessed on them during your next Joint Commission survey," says Paula Tanabe, RN, PhD, CCRN, advanced practice nurse for the ED at Northwestern Memorial Hospital in Chicago. (See key points of standards, p. 56. For information on obtaining a copy of the new standards, see Sources, p. 55.)
Darlene Matsuoka, RN, BSN, CEN, CCRN, clinical nurse educator for the ED at Harborview Medical Center in Seattle, says, "The standards ensure that the presence of pain is assessed, acknowledged, and treated more quickly than before."
Because there is a wider selection of interventions and treatments, ED nurses should evaluate the choices of pain management, question the use of conventional drugs, and consider alternatives, says Matsuoka. "The new standards will help solidify this proactive approach," she adds. The standards also require that EDs formally examine successes and failures of pain assessment and management, and identify opportunities for improvement.
The new standards are included in the 2000 JCAHO standards manuals and will be scored for compliance beginning in 2001. At mid-year 2000, JCAHO will assess the ability of accredited organizations to comply with the standards and put into place a plan for full or phased-in implementation.
Study: Pain is undermanaged in ED
According to a recent study of 203 ED patients, 78% came with a chief complaint of pain.1 But only 47% of those patients received an analgesic, and only 11% of patients with extremity pain received ice, reports Tanabe, the study’s principal investigator. "All these patients had stated they would not refuse an analgesic."
About 25 patients were afraid to be given opioids for pain relief because of concerns about addiction, but of these patients, only seven actually refused analgesics, she adds.
Always investigate the reasons why patients refuse pain medications, Tanabe recommends. "Correct misunderstandings or offer alternative medications or nonpharmaceutical approaches."
Here are some ways your ED can comply with the new Joint Commission standards:
• Educate yourself.
Take advantage of your facility’s pain management resources, advises 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 based in Des Moines.
"Many hospitals today have pain clinicians, because there has been a focus on the inpatient side for management of acute pain and chronic pain for many years," she says.
The pediatric units and pediatricians are excellent resources, as well as clinical pharmacists, says Spurlock.
Additionally, you can obtain consensus statements on pain management published by The American Pain Society and The American Academy of Pain Medicine, both based in Glenview, IL. (For information on how to obtain copies, see Resources, p. 56. For key points from the American Pain Society guidelines, see p. 57.)
• Address misconceptions about pain medications.
You should be comfortable giving larger doses for relief and not fear that the patient will become addicted, stresses Matsuoka. "The rationale of We need to monitor the pain so we cannot treat it’ does not obviate the need for patient comfort during the evaluation."
Physicians traditionally were taught that medicating patients who had abdominal pain was not only dangerous, but that it would lead to an inaccurate diagnosis, says Tanabe. In fact, research shows that analgesics do not alter the diagnosis and might lead to a more accurate one, Tanabe adds.2-4
• Prompt physicians to give pain medication.
Physicians tend to focus on diagnostic studies and treatments and sometimes overlook pain relief, stresses Spurlock. "When summarizing the patient’s presenting symptoms and objective data, ask the physician what they would like to give the patient for pain."
Prompting the physician to consider pain relief as a component of the first line of treatment decreases delays, Spurlock notes. "The physiological response of untreated pain research is valuable data to share with physicians, and it may impact their practice patterns," she recommends. (See Recommended Reading, p. 54.)
Include alternatives
• Offer nonpharmaceutical therapies.
Distraction, music, ice, and positioning are all effective for various types of pain, says Tanabe.
"Nurses must first educate themselves about these therapies to increase their comfort level, then educate their peers," she advises. (For information on a new publication available from American Health Consultants, publisher of ED Nursing, see p. 63.) "You need to practice effective pain assessment and management on a daily basis, and that includes alternatives."
• Give pain medication before patients are discharged.
Pain management should be a top priority, even with patients who are discharged home, says Spurlock. "The time interval it takes a patient to travel to a pharmacy and fill a prescription can be more comfortable if one dose of pain medication is administered before discharge or better yet, upon arrival," she recommends.
Patients with acute onset of back pain, simple fractures that have had application of a cast or splint, and children with otitis media who have been brought to the ED due to crying, would benefit from this approach, says Spurlock. "A more global approach to the decision making would be to consider administration of medications in any patient being discharged with a prescription for pain management."
• Make pain a fifth vital sign.
The new standards refer to pain intensity ratings as the "fifth vital sign," notes Emory Petrack, MD, MPH, chief of the division of pediatric emergency medicine at Rainbow Babies and Children’s Hospital in Cleveland. "Consistent assessment of pain is key."
This consistency requires assessing for the presence and intensity of pain in every patient who presents to the ED, Tanabe explains. "This can easily be done by adding a column to the documentation tool for pain next to heart rate, temperature, blood pressure, and respiratory rate. It should become as routine an assessment as the other vital signs." (See protocols for EMLA cream in the ED and renal colic pain, inserted in this issue.)
Ask yourself: "Is every patient in your ED assessed for pain?" advises Petrack. "For example, a patient who presents with a fall and a radial fracture will generally have their pain managed if a reduction is required. However, if the patient is not in obvious pain initially, he or she may not have their pain assessed and managed."
Ideally, the formal pain assessment should be performed using a specific pain scale, notes Petrack. "The pain will then need to be managed and reassessed during the ED stay," he says. (See story on pain assessment scales, p. 59, and Wong-Baker Faces Pain Rating Scale, p. 60.)
• Assess pain at triage.
Protocols should instruct nurses to ask all patients about pain at triage, advises Spurlock. "Exclusion criteria could be established, such as those who present with behavioral symptoms or infants who appear content." (See story on benefits of using pain management protocols, p. 57.)
At Mercy’s ED, patients are asked at triage if they are currently experiencing pain. "If the response is yes, we ask them to rate the severity of pain on a scale of 0-10, with 10 being the most severe pain. If the answer is no, a score of zero is entered," Spurlock explains.
Using pain scores as triage criteria is also an excellent screening tool, recommends Spurlock. "This is valuable during times when treatment rooms are at a premium and triaging the acutely ill is necessary. The Joint Commission will be interested in seeing that the information is used to improve care and impact the comfort of patients."
Recommended Reading
• Wilson J, Pendleton J. Oligoanalgesia in the emergency department. Am J Emerg Med 1989; 7:620-623.
• Selbst S, Clark M. Analgesic use in the emergency department. Ann Emerg Med 1990; 19:1,010-1,013.
• Friedland L, Kulick R. Emergency department analgesic use in pediatric trauma victims with fractures. Ann Emerg Med 1994; 23:203-207.
• Lewis L, Lasater L, Brooks C. Are emergency physicians too stingy with analgesics? South Med J 1994; 87:7-9.
• Ducharme J, Barber C. A prospective blinded study on emergency pain assessment and therapy. J Emerg Med 1995; 13:571-575.
• Salomone J, Price S, Watson W. A prospective evaluation of acute emergency department pain management. Am J Pain Manage 1995; 5:80-83.
References
1. Tanabe P, Buschmann M. A prospective study of ED pain management practices and the patient’s perspective. J Emerg Nurs 1999; 25:171-177.
2. LoVeccio F. The use of analgesics in patients with acute abdominal pain. J Emerg Med 1997; 15:775-779.
3. Zoltie N. Analgesia in the acute abdomen. Ann R Coll Surg Engl 1986; 68:209-210.
4. Pace S. IV morphine for early pain relief in patients with acute abdominal pain. Acad Emerg Med 1996; 3:1,086-1,092.
For more information about compliance with the new pain management standards, contact:
• Darlene Matsuoka, RN, BSN, CEN, CCRN, Harborview Medical Center, Emergency Department, Mail Stop 359875, 325 Ninth Ave., Seattle, WA 98104. Telephone: (206) 731-2646. Fax: (206) 731-8671. E-mail: dmatsuok@ u.washington.edu.
• Emory Petrack, MD, MPH, Division of Pediatric Emergency Medicine, Rainbow Babies and Children’s Hospital, 11100 Euclid Ave., Mail Stop MATH6097, Cleveland, OH 44106-6019. Telephone: (216) 844-8716. Fax: (216) 844-8233. E-mail: [email protected] or Emory.Petrack@ uhhs.com.
• Patricia Spurlock, RN, Neurological Associates of Des Moines, 1601 N.W. 114th St., Suite 338, Des Moines, IA 50325. Telephone: (515) 223-1917. Fax: (515) 223-0284. E-mail: [email protected].
• Paula Tanabe, RN, PhD, CCRN, Northwestern Memorial Hospital, Emergency Department, Feinberg Mezzanine, Suite 714, 251 E. Huron, Chicago, IL 60611. Telephone: (312) 926-6999, ask for pager No. 57696. Fax: (312) 926-6288. E-mail: [email protected].
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