Guest Column: Pain management: The fifth vital sign
Guest Column
Pain management: The fifth vital sign
Press, Ganey assesses how well you do
By Peter Lanser, MS,
CHE, CPHQ,
Director of Information Integration
and HIPAA Compliance
Sabina Gesell, PhD, Senior Research Associate
Press, Ganey Associates, South Bend, IN
The Joint Commission on Accreditation of Healthcare Organizations (JCAHO) had a marketing blitz in December to announce new pain standards. They were developed over two years in conjunction with the University of Wisconsin, Madison School of Medicine. The measures were designed to ensure all patients the right to appropriate assessment and management of their pain and underline that organizations have a responsibility to develop processes within their settings to help support improvements in pain management. The new standards make pain an issue for patient rights, staff competence, leadership support, and quality improvement.
Controlling pain in three settings
The commission’s accreditation manuals have 11 chapters organized by functions or activities that their accreditation process requires of ambulatory care, behavioral health care, home care, hospice, hospital, long-term care organizations, and networks. The new pain standards are contained within six of the 11 functional chapters.
We decided to examine national results of the Press, Ganey survey question: "How well was your pain controlled for the inpatient, ambulatory, and ED [emergency department] settings?" The study shows that pain is controlled better during ambulatory care than inpatient and ED situations. "Very good" ratings were given by 70% of ambulatory respondents. In contrast, "very good" ratings were given by only 44% of patients receiving emergency care and 53% of inpatient respondents.
The January 2001 inpatient response frequencies — 53% very good, 36% good, 8% fair, 2% poor, and 1% very poor — have remained constant since January 2000. Because the database is so stable, it should be sensitive to future changes in patient ratings. The question becomes: Will patient satisfaction increase with this new attention being paid to pain control or will satisfaction drop as patients recognize that they have the right to have their pain treated?
Our recent look at national responses to the pain control question identified other noteworthy results, as well. Cancer patients treated in an ambulatory setting — when evaluating the support they received in managing the various physical and psychological side effects of chemotherapy and radiation therapy — expressed the highest satisfaction with the support they received in managing their pain.
The national inpatient study shows that other variables impact patients’ satisfaction with pain management. In general, patients from our sample are less satisfied with pain control in teaching hospitals vs. nonteaching hospitals. Our data also show differences in patient satisfaction with pain control depending on American Hospital Association (AHA) region.
Patients in AHA Region 1 are significantly more satisfied with pain control than patients in other AHA regions. We found no difference, however, in satisfaction with pain control by nursing model (team, functional, primary, patient focus units) on noncritical care units. Additionally, inpatients are less satisfied with pain control in big cities compared to rural communities. However, one big-city teaching hospital that has had stellar ratings over the past two years is the Evanston (IL) Hospital.
Barbara Hocking, senior clinical director for medical, surgical, and outpatient services at Evanston Northwestern Hospital, stated that "the most crucial key to success has been the basic education program for all nurses, pharmacists, and residents/interns as it provided an excellent foundation for the pain management initiative. This grass-roots effort continues to be driven by committed clinicians who provide the education and the role modeling."
Press, Ganey has found that in addition to focusing on pain control for humane and accreditation purposes, pain control may be a competitive advantage. Looking at the inpatient setting in 2000, we have found that satisfaction with pain control is highly correlated with overall satisfaction with care (r= 0.7, p < .001, n = 770,405) and with patients’ likelihood to recommend the hospital to others (r = 0.56, p < .001, n = 770,405). These relationships are even stronger in the emergency department (r = 0.81, p < 0.001, and r = 0.75, p < 0.001, respectively).
Not only is pain control extremely important to emergency department patients, they also report the lowest levels of satisfaction with pain control compared to inpatient and ambulatory surgery patients. This combination of low scores and high relevance puts pain control in emergency departments (along with wait time) at the top of the national priority index for improvements.
Many organizations consider pain control directly related to their mission. The free data-linking services available from Press, Ganey allow organizations to look at issues such as pain control by DRG (diagnosis-related group) and MDC (major diagnostic category). The ability to stratify important issues such as patient satisfaction with pain management by clinical variables has enabled many of our clients to provide bedside caregivers with meaningful and actionable data.
Since JCAHO released its new pain standards, Press, Ganey has noticed a marked increase in the number of clients who have added custom survey questions in order to:
- assess how much pain the patient experienced;
- assess how well staff responded to expressions of pain;
- assess how well the patient’s pain was controlled throughout the hospital visit;
- assess the extent to which the patient was involved in deciding how their pain would be relieved.
One facility that has improved pain management by focusing on the issue and changing processes is Beebe Medical Center in Lewes, DE. According to Sue Howell, RN, Beebe’s director of inpatient care, "Control of pain afforded us many opportunities at Beebe Medical Center. As patients are well-educated in their rights and disease processes, it became apparent that we could improve in pain management," she says. "To change the process of pain control, we reviewed charts, analyzed our Press, Ganey scores and comments regarding pain, researched literature, talked with staff, and brought in an outside resource to discuss pain control with physicians and nurses."
She calls the research "an eye-opener for our medical center." An interdisciplinary team was formed to revamp the tools used for assessment and documentation and reevaluate the types of medication and methods of administration. Process changes included:
- Ordering new patient-controlled analgesia (PCA) pumps.
- Increasing the number of available PCA pumps.
- Using a new flowsheet for anesthesia and nursing.
- Initiating PCA pumps in PACU.
- Including only IV analgesia on the revised pain order.
- Including alternative methods of pain control on the revised orders.
- Increasing patient-controlled epidural analgesia usage has for abdominal as well as orthopedic surgery.
"The attention to detail and patient comfort is a focus for all the inpatient units," Howell continues. "Physicians, nurses, and nursing assistants take pain control as a serious matter and our Press, Ganey results are most encouraging. We are now in the 99% percentile as of the last quarter, increasing from 87% for the April-June 2000 quarter regarding the survey question on pain control."
Pain management: Greater satisfaction
The lowest-scoring issues in the ED are waiting time and pain management. One emergency department that has high ratings on the questions regarding pain control and staff sensitivity to pain is at Duncan (OK) Regional Hospital (DRH). The facility is extremely proud of the work being done by the staff to educate their peers, patients, and family members on patient pain control. A great deal of work, planning, and "creative" education has been put into place with an emphasis on making sure Duncan’s patients do not suffer with pain.
Gina Flesher, RN, education instructor and Cindy Rauh, RN, director of acute care services, state that, "Pain is the No. 1 symptom of the majority of all patients we see at DRH. It is the goal of the staff to ask 100% of our patients on admission to the ED if they are in pain. "If the answer is a yes,’ the next goal is to treat that pain within 30 minutes and reassess the intervention to bring that pain down below the level of 5 (on a scale of 1-10) within two hours, " she says.
"We are aggressive in our pain management, recognizing that the patient’s self-report of pain is considered the single most important indicator of pain," Rauh adds. There is also a monthly column in the hospital’s monthly newsletter, Viewbox, to educate not only the nursing staff, but the entire staff, on the hospital’s commitment to making sure our patients are comfortable.
In response to the increasing amount of interest in additional pain control questions, the Press, Ganey research and development team has developed a new selection of optional pain control questions. At this time, clients will not be required to add any pain control questions to their surveys. However, as new surveys are developed or as existing surveys are revised, the requirement of pain control questions will be assessed.
For example, during the revision of the ED survey it became clear that a standard pain control question was indeed necessary. All clients involved in the revision agreed upon this matter and numerous clients who were not directly involved in the development process called and wrote to us requesting that a pain control question be added.
Thus, how well your pain was controlled will become a standard question on the revised ED survey starting this spring.
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