Are your patients feeling more fear than pain? Improve patient education
Are your patients feeling more fear than pain? Improve patient education
Program wins 100% patient satisfaction, Joint Commission kudos
Fear of pain can be so gripping, it may cause your patients to put off getting needed surgery or even cancel a scheduled procedure. Advancements in anesthesia have improved postoperative pain management, but your patients may not know that.
Now same-day surgery managers are trying to educate patients about what pain control they should expect -- and demand -- during their recovery.
It's a matter of empowering patients for Barbara Duryea, MSN, RNC, COHN, director of education and director of quality improvement at Windber (PA) Hospital. They need both knowledge and choices about pain management, Duryea says. "When they come to the hospital, they shouldn't fear having pain after surgery," she says.
Using the acute pain management guideline of the Rockville, MD-based Agency for Health Care Policy and Research as a focus, Windber Hospital has achieved virtually 100% patient satisfaction with its postoperative pain management. (For more information on ordering guideline, see source box, p. 76.) The pain management program also won favorable comments from surveyors from the Joint Commission on Accreditation of Health Care Organizations in Oakbrook Terrace, IL.
That track record is far above the norm nationwide, according to a recently published study. About three-quarters of adults surveyed by researchers from Harvard Medical School in Boston reported they suffered pain after inpatient or outpatient surgery -- 80% of those said their pain was moderate to extreme.1
In fact, the expectation of pain can cause patients to suffer unnecessarily because they may not ask for relief, says Carol Warfield, MD, director of the division of pain medicine and the Pain Management Center at Beth Israel Hospital in Boston and associate professor of anesthesia at Harvard.
"Patients need to know that there are effective, safe treatments for pain," says Warfield, who adds that better patient education can ensure that patients speak up about inadequate pain relief.
Seeking better pain management
The failure of hospitals and surgery centers to adequately control postoperative pain prompted the Agency for Health Care Policy and Research to issue its clinical practice guideline in 1992. (For requirements and principles of pain management, see story at left.) Since then, many same-day surgery managers have worked to improve their patient education and pain assessment.
Windber Hospital took on postoperative pain management as a quality improvement project, even though patients had not reported inadequate relief. "We felt there was an opportunity for improvement in patient empowerment and educating patients preoperatively," says Duryea.
While the hospital had counseled patients about patient-controlled anesthesia, "we had not done a lot in saying to patients 'These are choices you have for pain management,'" she says.
Duryea developed seminars for nurses related to postoperative pain management. She uses patient brochures available from the Agency for Health Care Policy and Research, as well as a patient education video. In fact, she provides the brochures and video to physicians affiliated with the hospital, so the patient education can begin in their offices. (For information about ordering brochures or videos, see source box, p. 76.)
Nurses from the postanesthesia care unit (PACU) also contact patients the day after surgery to gauge their satisfaction with their pain management. (For a copy of the pain management questionnaire, see p. 75.) The survey routinely shows that 98% to 100% of patients were satisfied with their pain management.
Duryea stresses that Windber Hospital was able to implement this program with few expenses.
"We are a small rural hospital with less resources than a big medical center, and this was still possible for us," she says. "You don't need to have PharmD consultants and people who are doing this full time to help you.
"This is easily doable," she says. "The materials on guidelines are free, and the video was inexpensive."
How do you teach patients about pain? First, you need to recognize that patients may have very different expectations of pain, says Nancy Burden, RN, CAPA, CPAN, surgery team leader at the Morton Plant Mease East Lake Outpatient Center in Palm Harbor, FL.
Get inside the patient's head
While some patients may be terrified, others expect no pain at all, she says. "The nurse has to first find out what the patient is thinking or knows," Burden says of pre-op phone calls. "The nurse has to help the patient have a more realistic expectation of what's going to happen after surgery.
"I think the best approach is asking the patient, 'What's the doctor told you?' Most of the time, they have not had a big discussion about something so specific as pain. Usually their discussions are about the procedure and how soon they can get back to work," says Burden.
Because early treatment of pain is most effective, patients need to understand that they should speak up as soon as they feel discomfort in the PACU, she says. Patients are advised that they should call their physicians if their pain medication isn't providing sufficient relief once they're home, Burden says.
Before surgery, nurses in pre-op education tell patients about choices they may have in anesthetic agents. The pre-op nurses then need to pass that information to the nurses and anesthesiologist who will work with the patient on the day of surgery, Burden says. "We make sure that everybody on the team follows through with what we've told the patient we'll do for them," she says.
Burden also is conducting an outcomes study to determine how well the surgery center is managing postoperative pain. In a postoperative telephone survey of a sample of patients, nurses will record the worst pain level before medications or interventions and the least after intervention. They will also record the medicines we gave and whether PACU nurses treated nausea and vomiting.
"We want to know how well patients feel their pain was managed during the procedure," Burden says.
Specialists may help in severe cases
For those difficult cases of unresolved pain, same-day surgery managers may want to make sure patients have access to an anesthesiologist who specializes in acute pain management, says Warfield.
"There are patients who have straightforward cases, where the surgeon can very adequately treat the patient," she says. "For more complicated problems, a pain management specialist can provide a consult."
For example, if a patient has been treated for postoperative pain, but on a scale of 0 to 10 still reports feeling a pain level of 5, a consult with a pain management specialist would be reasonable, she says.
Same-day surgery managers also can highlight the issue of postoperative pain management through educational forums with physicians, using an anesthesiologist specializing in that area as a speaker, she says.
Warfield also has a suggestion of what to tell patients preoperatively about pain: "There are very, very adequate ways of treating pain after surgery. Here are your options of treating pain," possibly including nerve blocks, medication, and patient-controlled pumps.
An anesthesiologist may discuss the options of postoperative pain control in a pre-op visit and may explain the facility's method of rating pain intensity. But Warfield is upbeat: "We'll endeavor to make [your surgery] pain-free," she tells patients. "We'll adjust the medications until you're satisfied with the amount of pain relief."
At Windber Hospital, a focus on patient education and acute pain management had a side benefit. A multidisciplinary committee, including nursing, medical, and pharmacy staff, presented the acute pain management program to surveyors from the Joint Commission and won favorable remarks.
"It made the whole survey process a little less painful," says Duryea. *
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