Patient/staff partnerships lead to better pain management
Lessons on assessment, pain control methods a must for JCAHO compliance
Pain has become a major focus of education since the Joint Commission on Accreditation of Healthcare Organizations in Oakbrook Terrace, IL, added specific instructions to its standards this year. These instructions include appropriate assessment for pain and its cause and education of staff and patients on pain management.
The medical systems that already had pain management programs in place have simply had to tweak them to fit the standards. For example, in 1997, St. Francis Medical Center in Honolulu established standards for pain management that include education of patients and staff. They also added pain assessment into their patients’ rights policy and incorporated pain as a fifth vital sign. The one improvement made since the standards were implemented is to focus more on how all disciplines assess for pain, rather than just focusing on nursing, says Amy Krueger, RN, MSN, FNPC, a nurse practitioner in pain management at St. Francis.
The Ohio State University Medical Center in Columbus had developed several education sheets on pain relief and had implemented a procedure for pain assessment, but a task force has now been assembled to make sure the medical facility has addressed all the issues covered in the standards.
"The task force is looking at process improvement initiatives on pain management, revising the pain assessment process, looking at pain management initiatives across the continuum of care, staff education in pain management, and producing pain management handouts specific to patient populations such as the elderly," says Sandra Cornett, RN, PhD, program manager for consumer health education at the medical center.
The Joint Commission standards on pain education and management are long overdue, says Patricia Collins, RN, MSN, clinical nurse specialist in oncology/pain at Baptist Health Systems of South Florida in Miami. While pain management and education were already addressed at this multihospital health care system, the standards provide an impetus to get every discipline on board. "When the standards came into place, it created more of an awareness and more of an urgency with getting everyone up to speed," says Collins.
While the standards are an incentive to fine-tune programs and spur people on to perfection, what do you do if you are starting from scratch? The institutions that had a framework in place before the standards were implemented are good examples for those institutions struggling to implement policies and procedures.
Physicians need advice on pain management
Most facilities have a system that establishes experts who can provide advice to clinicians on pain management. At The University of Texas MD Anderson Cancer Center in Houston, the Symptom Control & Palliative Care Center acts as a consultative service for both inpatient and outpatient areas. If a clinician diagnoses a patient as having pain, nausea, cachexia, or any symptom caused by cancer, the clinician can request a consult through this service, explains Karen Stepan, MPH, CHES, health education coordinator at MD Anderson.
Following a comprehensive interdisciplinary assessment, members of an interdisciplinary team work together to establish a plan of care that includes pain management. An institutional initiative is under way to include the Symptom Control & Palliative Care Center team as an integral component of all disease-specific clinical pathways. Upon clinician request, the team would provide a symptom assessment and overall plan of care for patients with advanced cancer.
To help clinicians on a routine basis, the Symptom Control & Palliative Care Center created cancer pain guidelines that provide a step-by-step decision making process on how to treat the type of pain the patient is having. The center also created a preprinted prescription pad that identifies pain treatment options based on severity of pain, says Stepan.
Baptist Health Systems has a Pain Resource Nurse (PRN) program in place systemwide and has trained 300 nurses to provide help with complex pain problems or patient education issues that may arise on the units. This program, which is patterned after a model created at City of Hope Cancer Center in Duarte, CA, also is used at St. Francis in Honolulu. "Those caring for the patient need resources readily available. We would like to have one PRN on each shift," says Krueger. St. Francis also has a pain management service that can be contacted for patient consultations. The team of experts includes nursing, physical therapy, spiritual services, social work, psychiatry, and neurology.
In addition to having a resource for expert advice on pain management, it is important to educate both staff and patients about pain and its assessment. "The biggest issue of pain management is the myths and misconceptions about it and proper assessment," says Krueger. Many clinicians were taught to look for behavior cues for pain and now they must be taught to rely on what the patient tells them. Most patients at St. Francis are asked to assess their pain on a scale of one to 10, with one being very little or no pain and 10 being excruciating pain.
Patients as partners
"Patients must be taught that they are an important partner in their pain management," says Collins. To be effective partners, patients must understand how their pain will be assessed. That’s why they are given a tip sheet upon admission to Baptist Health Systems that explains the importance of pain assessment and what questions they will be asked. For example, staff will want to know where patients’ pain is located, what it feels like, how bad it is on a zero-to-10 scale, what helps their pain, what makes it worse, and how the pain interferes with their ability to eat and sleep.
To help patients better manage their pain, educational materials should be provided. When patients are admitted to St. Francis, they are given a patients’ rights brochure that includes information about patients’ right to receive pain assessment and management. They also receive a sheet titled "Talking About Your Pain" that reviews the pain assessment process. Handouts specific to the course of therapy also are available, such as cancer pain management or post-op pain management. (For examples of pain education sheets, see pain education handouts from The Ohio State University Medical Center, inserted in this issue.)
Patients who receive a consultation with an interdisciplinary team from the Symptom Control & Palliative Care Center at MD Anderson are given a medication record and a written and audiotaped version of their plan of care and question-and-answer period with the team. The patient can easily use the tape as a reference, explains Stepan.
Before creating a plan of care, the team completes a thorough assessment of the patient. Tools used to evaluate patients’ pain include a symptom assessment that rates a patient’s perception of pain, fatigue, nausea, depression, anxiety, drowsiness, shortness of breath, appetite, sleep, and feeling of well-being on a scale of zero to 10. Also used are a Mini-Mental State Examination to screen for cognitive impairment and a Cage Questionnaire used to assess the patient’s coping mechanisms and the likelihood of a patient using chemicals to cope with stress.
The Mini-Mental State Assessment was developed by Marshal F. Folstein, MD, at Medford, MA-based Tufts University School of Medicine. The CAGE Questionnaire was developed by staff at Johns Hopkins University in Baltimore. Both assessments, along with instructions for their use, can be obtained from the Edmonton Palliative Care Program at the University of Alberta Department of Oncology (www.palliative.org).
To help complete the partnership, staff also must receive education on pain management. At St. Francis, in addition to a basic four-hour pain management class, staff can go on rounds with the pain management service once a week to discuss patients who are currently on the service and their pain etiology and treatment, says Krueger. Those who go on rounds can receive continuing education credits. (For more information about pain etiology, see article on chronic pain management, below.)
A big issue for both patients and staff is the fear of addiction, says Collins. "Many patients think addiction and medication for pain go hand-in-hand. They don’t understand that addiction is when people take pain medications for reasons other than pain. We spend a lot of time on this subject, and it is discussed on the patient tip sheet," she says. The topic also must be addressed in staff education.
Policies and procedures similar to the ones described in this article can easily be designed to fit your health care system and implemented in compliance with Joint Commission standards. "Our program has been in place for some time," says Krueger. "We have pretty much covered all the pain management standards, and it is not an overwhelming task to do so. The standards are very basic."
[Editor’s note: The Joint Commission standards, including those on pain education and management, can be found on its Web site at: http://www.jcaho.org.] n
For more information on complying with Joint Commission standards on pain education and management, contact:
• Patricia Collins, RN, MSN, Clinical Nurse Specialist in Oncology/Pain, Baptist Health Systems of South Florida, 6200 S.W. 73rd St., Miami, FL 33143. Telephone: (305) 662-8139. Fax: (305) 663-5092. E-mail: [email protected].
• Sandra Cornett, RN, PhD, Program Manager, Consumer Health Education, Department of Consumer/ Corporate Health Education & Wellness, The Ohio State University Medical Center, 1375 Perry St., 5th fl., Columbus, OH 43210. Telephone: (614) 293-3191. Fax: (614) 293-3690. E-mail: [email protected].
• Amy Krueger, RN, MSN, Nurse Practitioner Pain Management, St. Francis Medical Center, 2230 Liliha St., Honolulu, HI 96817. Telephone: (808) 547-6109. Fax: (808) 547-6292. E-mail: [email protected].
• Karen Stepan, MPH, CHES, Health Education Coordinator, The University of Texas, MD Anderson Cancer Center, 1515 Holcomb Blvd., Box 21, Houston, TX 77095. Telephone: (713) 792-7128. Fax: (713) 794-5379. E-mail: [email protected].
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