Try these tips for improving pain management program
Program focuses on improving assessment
A university-sponsored pain management improvement program for home health provides a blueprint for agencies seeking to better assess, manage, and document pain care.
And it couldn’t come at a better time, as agencies cope with the latest requirements from the Oakbrook Terrace, IL-based Joint Commission on Accreditation for Healthcare Organizations (JCAHO). JCAHO last year released pain management standards that will be a part of this year’s surveying and will be scored for compliance in 2001.
The program, sponsored by the University of Wisconsin’s Pain Management Improvement Group, worked with 53 Wisconsin agencies in settings that ranged from urban to rural. Nurses from each agency studied their own pain management practices, and learned how to improve them.
The results, gathered six months later, pointed not just to better-educated nurses and patients. Researchers found a 5% increase in physicians’ ordering of opioids, a change the researchers say is attributable to better-educated nurses educating doctors.
"I was really blown away by that," says Karen Kunz Stevenson, RN, MS, of the Pain Management Improvement Group at the University of Wisconsin in Madison. "I didn’t expect to see a change in patterns that quickly."
The steps outlined by the group, as well as similar work sponsored by the City of Hope Pain Resource Center in Duarte, CA, can help agencies get a head start on fulfilling the JCAHO pain management standards.
Program starts with needs assessment
Stevenson says she recruited teams from home health agencies in the Eau Claire and Madison areas, asking that they send at least one person who could effect change in the agency in the area of pain management. Many were directors of nursing; some agencies sent up to five staffers.
The group took the teams through three educational sessions. In addition to receiving basic pain management education, teams conducted needs assessments of their own organizations, rating themselves in areas such as administrative support, documentation, policies and procedures, accountability, staff education, and patient information. (See "Home Health Agency Needs Assessment," inserted in this issue.)
"They included things like, Does their documentation system screen for the presence or absence of pain?’" Stevenson says. "Do they have a standardized pain scale? Do they have some sort of documentation that cues the nurse to do a complete pain assessment?’"
Teams also conducted random chart audits in their agencies to look at the same issues.
From that information, the teams formed work plans for their agencies and brought them to follow up sessions, guiding the group in the areas that should be covered. Those topics included chronic pain management, complementary therapies, pharmacology, nonpharmacological interventions, and how to communicate with doctors about pain management.
"[The sessions] kept people engaged and coming back; they also had to keep reporting back to us," Stevenson says. "At the end of the program, we did another site visit. They showed us the things they had worked on, and we looked at the changes that had actually occurred in agency practices."
Researchers found marked improvement in nearly every area except pain scales, which already were fairly universal in use.
Laura Kiesow, BSN, RN, staff nurse at Hillside Homecare/Hospice in Beaver Dam, WI, says her agency had already implemented many of the improvements suggested by the program.
But she says her agency’s involvement did lead to some fine-tuning, particularly in its assessment tool that nurses fill out on laptop computers.
"We were limited by the software program we had, which was inadequate," she says. Hillside ended up enhancing the software with keywords a nurse could type in to call up a pain management checklist to help collect the necessary information.
Similar enhancements were made to the software that produced the agency’s care plans.
"We rewrote our care plan to include some of the areas we were missing, such as patients’ misconceptions and barriers," Kiesow says. "We weren’t always doing an assessment of why they might not comply with medication — what they might be afraid of, such as side effects.
"We also were not always doing a preventative bowel management program [to help prevent problems with constipation for patients taking opioids], so we included that in the care plan."
Research scientist Betty Ferrell, RN, PhD, at the City of Hope Pain Resource Center in Duarte, CA, found that when she tried to study how patients and caregivers responded to education about pain, she first had to instruct area home health nurses in how to conduct the education.
"The nurses had to know it before they could do it themselves," Ferrell says. "We did a basic pain training for the nurses and then they could really do the things to teach patients, overcome the patients’ fears, and coach the family in how to manage pain at home."
City of Hope also gave agencies information about nondrug interventions such as relaxation therapy and massage, which are increasingly popular among patients.
City of Hope’s own home health agency is in the midst of its own pain management audit, which has turned up some suggested changes, says director Terry Daggi, RN, MSN.
"One of the things we’ve noticed is that unless you have the appropriate tool already embedded within your regular documentation, people forget," Daggi says. "If they actually perform good pain control assessments and interventions, oftentimes they will forget to document that."
She says pain assessment is pretty comprehensively addressed on the agency’s initial assessment form, but follow-up forms are less complete, and need revamping. "We’ve done enough chart audits to know that we’re only recording all of what I consider the required elements about 25% of the time."
She’d also like to see a pain management knowledge assessment tool that can be used with new staff. And she likes the idea of including in a patient’s admission packet an explanation of his or her rights to pain management.
An agency seeking to improve its pain management practices needs to incorporate a number of important elements:
• Organization. Often, Kiesow says, an agency will try to tackle the problem with one memo and an inservice.
"To really have an effect, you need to have a committee that looks at issues of assessment, documentation, teaching, and develops an ongoing program so it will stay in effect, even when you have a turnover of staff."
• Interdisciplinary participation. This is vital, Stevenson says. In fact, she regrets not actively recruiting more physical therapists (PTs) for the initial home health study.
"There’s so many people whom PT follows independently, and virtually all of those patients have pain," she says.
• Parameters for pain assessment. In reviewing many agencies’ charts, Stevenson says she often couldn’t tell whether patients were experiencing pain at all. Documentation is obviously key.
Beyond that, the agency must establish thresholds that require some type of action on the staff’s part "Once you know the patient has pain, the nurse has to do a complete pain assessment," she says. "They should set a standard so they decide when you have to follow pain as a problem.
"If someone has periodic headaches where the pain score never gets worse than three out of 10 and they take Tylenol a couple of times a month, I wouldn’t say that a home health agency really needs to follow that as a problem. But compare that to someone who has arthritis, and their pain score’s eight out of 10, and it’s limiting their activity on a daily basis."
She says that when something is identified as a problem, there should be a standard that tells staffers they can’t leave the house without intervening in some way.
"That doesn’t necessarily mean changing med orders," Stevenson says. "You can do patient education and realize that the patient isn’t taking their medication properly because they’re afraid they’re going to get addicted."
• Resources. Agencies should be providing staffers with tools such as reference cards and handbooks to help them figure out what to do.
• Karen Kunz Stevenson, Pain Management Improvement Group, University of Wisconsin-Madison, 1300 University Ave., Room 4720 MSC, Madison, WI 53706. Telephone: (608) 265-5368. Fax: (608) 265-4014. E-mail: [email protected].
• Betty Ferrell, Research Scientist, City of Hope Pain Resource Center, 1500 E. Duarte Road, Duarte, CA 91010-3000. Telephone: (626) 359-8111. E-mail: [email protected].
• Terry Daggi, RN, MSN, Director of Home Health, City of Hope, 1500 E. Duarte Road, Duarte, CA 91010-3000. Telephone: (626) 359-8111. E-mail: [email protected].
• Laurie Kiesow, BSN, RN, Staff Nurse, Hillside Homecare/Hospice, 709 S. University Ave., Beaver Dam, WI 53916. Telephone: (920) 887-4050. Fax: (920) 887-6815.
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