3 little questions reduce pain, boost satisfaction
3 little questions reduce pain, boost satisfaction
Attitude shifts, low-tech devices create success
Too many patients left unhappy after they were discharged from Hermann Hospital in Houston. They wouldn't give you a hill of beans for their overall satisfaction, and they especially thought providers paid too little heed to soothing pain.
No matter where performance improvement director Katharine Luther looked, patient satisfaction was too low, but the 32-bed Orthopedics Unit occupied bottom rung.
Finding an eager partner in unit director Tommye Cashaw, Luther facilitated a rapid cycle improvement process that raised patient satisfaction in Orthopedics and other departments. Even in the first month, the unit's "good/excellent" ratings for pain control jumped from 60% to 72%. Ripple effects spread throughout the institution.
Most nurses come from the let-'em-ask philosophy of dispensing PRN (upon request) pain medications, Luther says. Patients unwittingly complicate pain control by waiting until it's extreme before turning on the call light.
"By the time the nurse checks the chart for the dosage - which probably wasn't high enough in the first place - finds the narcotics key, goes to the cart, and does several other things before she gets back to the patient's room, a half-hour or 45 minutes go by. By then, the pain is so bad the meds are ineffective," Luther says.
Readjusting attitudes
The first change targets were the nurses' misconceptions about pain control. The nurses would ultimately show the patients that managing pain depends on taking the meds before pain gets unbearable. Inservice training sessions taught new approaches and offered discussion forums to air attitudes about drug use.
Many of the nurses didn't understand the equivalences of oral and intravenous (IV) or intramuscular (IM) pain meds. When patients came off of self-administered IV or IM pain control from patient-controlled analgesia pumps, the strength of the oral medications have to be as potent as what they were getting from the pump or "You might as well throw it away. It will not control the pain." Luther stresses. The nurses also learned that a person won't get hooked by receiving therapeutic doses of morphine for two or three days after surgery.
More complex and subtle than knowledge gaps were the moralistic attitudes many nurses carried to the bedside, Cashaw explains. "They took a somewhat passive-aggressive approach to the elective surgery patients.
"They kind of felt the elective patients didn't need the pain meds as badly as the trauma patients, so the electives got less attention." She adds that as part of the improvement process, elective patients are now in a separate unit.
Attitudes about addiction also came up for discussion. "Some of our patients have a history of drug abuse," she says, "and the nurses were afraid they would make it worse by giving them narcotics for pain. We had to get it straight that we're not there to reform them in three or four days. Our job is to medicate their pain so they can get out of bed and start moving again."
The final phase of attitude adjustment was individual contracting to accept personal responsibility for patient pain control. Both clinical and support staffs make the commitment. Their goal is a 15-minute turnaround on pain med requests. The individual contracts internalize the commitment, thus curbing the impulse to treat the pain control goal as externally imposed.
Cashaw discusses the unit's policy with float (temporary) nurses. If their ethical or moral values would interfere with buy-in, they can simply ask another nurse to handle pain med requests.
In addition to attitudinal changes, the improvement process involved the purchase of four pocket phones for the nurses, costing a total of $1,200. This enables the secretary and other caregivers on the horseshoe-shaped unit to quickly locate someone to access the narcotics box.
Beyond retraining and putting a phone in every nurse's pocket, the rest was low-tech. Luther describes three simple interventions that virtually transformed patient satisfaction in Orthopedics and other units as well:
1. When a caregiver goes into a patient's room for any reason, he or she asks, "Do you need water, pain meds, or the bathroom?"
The reason: "When a patient light goes on, 90% of the time they want one of three things - a drink of water, going to the bathroom, or pain meds," Luther says. "Asking the question puts caregivers into an anticipatory mode so they don't spend their whole day taking care of things they could have done on their last visit."
PRN meds are offered on a regular schedule whether patients ask for them or not. Of course, patients can decline the pain medications.
2. A clipboard hung by the unit secretary's phone tracks fulfillment of pain medication requests.
The secretary posts the time of the call and watches for a checkoff. If 10 minutes goes by and the patient is still waiting, the secretary flags down a nurse to take care of it. "I have nurses all over the hospital tell me how much that clipboard by the phone helps," Luther says.
3. Two team leaders per shift carry narcotics keys.
"Who would've thought a second set of keys would make such a difference!" Cashaw marvels at the psychological value of that little change. In addition to saving time, she explains, it's reassuring for caregivers to know that attending one patient's PRN request will not set them too far behind in completing their other duties.
Results from the orthopedic pain management improvement process are enough to keep everyone motivated for the changes ahead. Good/excellent satisfaction ratings climbed from the March 1997 baseline of 60% to 90% in June and July 1997. While they dropped in August when the census was high and float staff increased, the ratings were still at least 12% higher than the baseline. Cashaw and staff are applying the process that worked so well for pain control to speedier response times for all other patient requests. (For the overall pattern of satisfaction ratings, see chart, p. 98.)
Management is considering her proposal to use her unit as a test site for a $75,000, hands-free communication system. Through electronically coded badges, the COMposer system could locate staff members instantly and track patient calls and response times [Hill-Rom, Batesville, IN, (800) 638-2546]. She's developing a protocol for integrating float nurses into the quick response policy so she can cross-train others to orientate them. Cashaw calls the overall staff attitude toward the change process "upbeat because they really want to take good care of their patients."
[For more on introducing rapid cycle quality improvements through small changes, contact:
· Tommye Cashaw, Orthopedics Trauma Surgical Unit, Hermann Hospital, 6400 Fannin, Houston, TX 77030. Telephone: (713) 704-5178.
· Katharine Luther, Director, Performance Improvement, Hermann Hospital, 6411 Fannin, Houston, TX 77030. Telephone: (713) 704-2312. E-mail: [email protected].]
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