Home care agencies focus QI attention on better managing patients’ pain
WI research center offers training program
About 4,000 home care and other health care patients in Michigan and thousands more in five other states are benefiting from a special pain initiative that is focusing on training nurses how to more accurately assess and treat pain.
In recent years the federal government and independent accreditation organizations have begun to recognize how traditional health care has not adequately addressed the issue of pain management, except in the case of hospice patients. According to the American Pain Society of Glenview, IL, acute and chronic pain cost an estimated $100 billion each year in medical bills and lost workdays. Often primary care physicians are unaware of their patients’ pain, and it will go untreated unless other providers identify the problem. (See article, p. 99.)
To help nurses and other health care professionals learn how to assess and manage pain, the American Alliance for Cancer Pain Initiatives (AACPI) in Madison, WI, is using a grant from the Robert Wood John-son Foundation of Princeton, NJ, to educate health care professionals at home care agencies, nursing homes, and small community hospitals in Michigan, Virginia, Connecticut, Delaware, New Mexico, and North Carolina.
Called Institutionalizing Effective Pain Manage-ment Practices, the project involves data collection, use of standardized patient interview tools, and analysis of outcomes.
"There are two purposes to the grant, and one is to improve awareness of state cancer pain initiative programs so they’ll be seen as resources for the community in that state," explains Penny Murphy, MS, RNC, CRNH, project director of the Michigan Cancer Pain Initiative of Fenton, which is leading the pain project in Michigan.
"The other major focus is to help institutions bring pain management to their organizations to improve the overall practices of pain management," Murphy adds.
Education is key
Both the public and health care professionals need to learn more about pain management because the prevailing belief is that pain must be tolerated and even expected when a person is recovering from surgery, sick with disease, or simply old, notes Donna Mullen, RN, BSN, program coordinator for North Carolina’s Pain Initiative in Raleigh.
"What we’re hoping to accomplish is a change in people’s understanding," Mullen says. "Pain may be a natural result of disease processes but it can be managed."
AACPI established the project to focus on acute, chronic, and cancer pain, and the organization chose to provide training to nurses other than those in hospice and large hospital settings. However, in Michigan, news of the project is spreading, and two large health systems have already sent representatives so they can learn about pain management and later teach it to nurses and others in their institutions, Murphy says.
"The principal investigators out of Wisconsin felt that hospice had their act together and had already institutionalized pain management in those organizations," Murphy says.
Focus is on home care, not hospice
Murphy began to recruit home care agencies, nursing homes, and small hospitals in January 2001 and now has more than 20 organizations involved in the Michigan part of the project.
Lutheran Home Care Agency & Hospice of Hope in Frankenmuth, MI, is one of the small rural agencies involved in the project.
When Lynn Zuellig, RN, BSN, hospice director, received word of the pain initiative, she was enthusiastic about participating because the agency had recently opened its hospice division and could benefit from learning about cutting-edge pain research projects.
"Then I realized that they believed hospices were already doing good pain management and control, and the thrust of this would be toward nonhospice agencies," Zuellig says.
Zuellig then discussed the project with the agency’s home care director, Donna Zwerk, RN, BA, and they decided to make it a joint effort involving a team of three people, including Zuellig, Zwerk, and a staff nurse who worked
for both hospice and home care.
Outcomes have not yet been measured, but there have been some noticeable improvements in how staff nurses document patient pain and put it in the care plan, Zwerk says.
Also, home care nurses are more sensitive to their own mistakes in managing patients’ pain. For example, one nurse had called a physician’s office about a home care patient’s pain and had been told that the doctor would call the patient that day, Zwerk recalls.
"The nurse left a message for the case manager and went home, but the patient called in the morning, saying she was still in pain and had never heard from the doctor," Zwerk says.
Having learned more about pain management through the project, the nurse realized that she should have called the patient again at 4 p.m. to see if the doctor had called and prescribed medication. That way, the nurse might have been able to do something to help the patient before the doctor’s office closed, Zwerk adds.
Lutheran Home Care agency’s hospice is doing a separate study of pain management and assessment, although this information would not be part of the Michigan pain project, Zuellig says. (See story about the agency’s pain education and quality improvement [QI] projects, right.)
Pain management is QI project
Another agency involved in the project, United Home Health Services Inc. of Canton, MI, has made pain management a QI project and a top priority for staff, says Penny Rhein, BSN, RNC, vice president of the western, freestanding, hospital-affiliated agency.
"We’ve added additional cues for assessing pain and have made sure the grading scale we have is consistent with other parts of documentation, including the nurse’s notes," Rhein says.
The agency follows the American Pain Society’s recommendations to make pain assessment the "fifth vital sign" for each nursing visit.
"On the nurse’s notes for every visit, at the tip, we have spaces for pulse, blood pressure, temperature, respiration, and now there’s a line for assessing pain, which is the fifth vital sign," says Linda Mlynarczyk, BSN, RNC, clinical director.
"So it’s just a routine to assess a patient for pain," Mlynarczyk adds.
Implementing techniques
United Home Health Services also has implemented a variety of pain management techniques learned from the project. For instance, Rhein and Mlynarczyk learned about comfort care kits after attending a pain project workshop.
"This is a way for patients to concentrate on something other than their chronic pain condition," Rhein says.
Also, the agency has obtained a donation from a pharmaceutical company that will cover the cost of some of the comfort care kits, and the staff are looking into obtaining donations of packet items, such as relaxation tapes, personal massagers with rollers, massage oils, and creams, Mlynarczyk says. (See story on how United Home Health Services has educated staff and implemented pain management strategies, p. 103.)
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