St. Luke's makes pain the fifth vital sign, cuts costs
PACU cuts delays in transfers out of unit
Pain is now the fifth vital sign after temperature, blood pressure, pulse, and respiration at the post-anesthesia care unit (PACU) at the 949-bed St. Luke's Episcopal Hospital in Houston. This unusual step is part of the PACU's effort to make pain an outcomes management concern.
Implementing pain initiatives saved the PACU $18,248 in the first year, and average delay time in transferring out of the PACU was cut by more than half.
The effect of pain on recovery and behaviors associated with recovery is well documented. At St. Luke's, pain was identified as the major cause of variance in length of stay, accounting for 30% of all delays in transfer out of the PACU, says Pamela E. Windle, RN, MS, CNA, nurse manager for post-anesthesia for the hospital. The average delay time attributable to unrelieved pain was 85 minutes. In the PACU, a delay of one minute costs about $2.41 on average. Therefore, the total loss incurred by the unit per case due to unrelieved pain was $204.85, or $4,301.85 per month (figuring an average of 21 cases), or $51,622 annually.
How to identify pain
Quality issues regarding pain were also a concern, Windle says. The bottom line was that patients had unrelieved pain, and that unrelieved pain affected their physiological state and satisfaction with their care. Pain intolerance was defined as patients still experiencing pain after receiving some type of pain medication. Determining how much pain was acceptable in the immediate postoperative period and how to measure that pain proved troublesome.
One obstacle to measuring pain is deciding which tool to use and how to use it, says Susan Houston, PhD, RN, director of outcomes management and research at St. Luke's. The tools to measure pain differ in terms of reliability and usability, she says. For instance, the visual analog scale gives you a single number to measure pain, whereas the McGill Pain Inventory gives you a description of the pain (moderate/severe, location, continuous/intermittent).
The pain management program in the PACU is part of an overall effort to reduce pain throughout the hospital's patient populations, Houston says. The management processes differ, but hospital staff are working on pain in oncology, orthopedics, cardiovascular surgery, and labor and delivery. Several years ago, the hospital had tried a global approach to pain that was largely ineffectual, Houston says, but she believes this latest effort will be more successful. "Now that we're several years into outcomes management and measuring, people are much more accustomed to it and don't see it as a threat," she says.
Multidisciplinary team formed
The first step was the formation of a multidisciplinary team to examine pain management and its implications on quality and cost. The team consisted of PACU staff members, an anesthesiologist, an outcomes manager, a pharmacy representative, and a nurse manager. The group set ground rules to avoid any departmental turf battles, Windle says. Everyone agreed to commit to resolving problems.
The team tried to identify the causes of patients' pain intolerance. Some contributing factors included type of surgery, pre-existing conditions related to the patient, and variations in practice related to pain management practices. The team then hypothesized which factors were the greatest contributors to the variance and identified the following:
* lack of education among practitioners regarding current medications of choice and administrative routes;
* the numerous variations in practice among nurses and physicians regarding analgesics and pain control interventions;
* poor preoperative patient education for pain management.
Charting the key factors
To come up with those three, the team first brainstormed using a fishbone diagram and came up with dozens of factors. To narrow down the list, team members then were asked to rank the factors on importance on a scale of one to 10, until an agreement was reached.
The team then developed an action plan to reduce the variances and set out performance measures to monitor the plan's impact. The measures included the number of health care practitioners receiving education about pain management, the number and use of new protocols developed to standardize care practices associated with pain management; and the need to insure that all patients received good instructions from nurses and doctors regarding pain tolerance before surgery.
New protocols were developed by studying the literature, including the Rockville, MD-based Agency for Health Care Policy and Research acute pain management guidelines, current research about medications, the timing and administration of medications, existing data, and current practice commonalities, Houston says.
5 steps to tackle problems
Outcomes management initiatives designed to address the problems began in the fall of 1994. Those initiatives were as follows:
* Pain was included as part of the routine assessment in the postoperative period, making it the fifth vital sign. Documentation of pain became a quality improvement issue that was monitored on a monthly basis.
* Nurses were given inservice instruction on the use of a verbal rating scale from 0 (no pain) to 10 (worst pain), to assess pain.
* The team set a standard of 4 to 6 on the pain intensity scale that was considered "acceptable." Patients who reported a pain scale intensity of more than 6 remained in the PACU until they reported a pain rating of 6 or less.
* Patient-controlled analgesia was initiated in the PACU, not on the floor; therefore, drug levels were not subject to fluctuations that allowed for breakthrough pain.
* The PACU staff participated in intensive inservices on the guidelines for acute pain management by the Agency for Health Care Policy and Research. A copy of the clinical guidelines was kept in the unit for easy reference.
After the team implemented its pain initiatives, the average length of stay in the PACU due to unrelieved pain was 40 minutes, a 45-minute decrease. Total cost per case due to unrelieved pain was $96.40, half the cost before the pain initiatives were implemented.
Windle says a committee is in the process of changing its treatment pathways for pain. Future plans include assessing the perception of nurses as to how they treat pain and developing a pain algorithm.
[Editor's Note: Free copies of the clinical guidelines for acute pain care are available from the Agency for Health Care Policy and Research Publications Clearinghouse, P.O. Box 8547, Silver Spring, MD 20907-8547; or call (800) 358-9295.] *
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