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Update on TJC's focus on pain today
Paul Arnstein, RN, PhD, clinical nurse specialist for pain relief at Massachusetts General Hospital, is familiar with The Joint Commission's standards on pain. As president of the American Society for Pain Management Nursing and a liaison representing pain management, Arnstein recently attended an annual meeting with TJC.
Among the top 10 standard compliance issues for 2009 was clear and accurate medication orders (MM.04.01.01). Arnstein shared with Hospital Peer Review what he took away from the meeting:
"Too often, there are prescriptions for multiple simultaneous PRN analgesic orders that may represent a physician delegating clinical decision-making to nurses in a way that is beyond the scope of nursing practice. This may vary by state, so organizations should know what, if any related decision-making, is authorized in your locality. Some states specifically address the titration within a range order as part of nursing decision-making authority. Where the state makes no reference to this practice as being in or out of scope, the institutional policies are examined and the organization is held to those policies. In general, three or more simultaneously active orders for PRN analgesics raise a yellow flag that the medications orders are not clear enough. When asked directly, top leadership of the standards interpretations group said that there is no requirement linking a dose of analgesia to a number or a pain scale; no requirement to delineate mild, moderate, or severe pain; and no required sequence (e.g. try x first then y...) of choosing an analgesic to administer."
Shifting focus from TJC
"The Joint Commission is shifting its focus from seeing that all patients regardless of their condition are screened for pain, to one that addresses the patient who has been identified as having a problem with pain. For those patients with pain, they want to see that a 'comprehensive pain assessment' has been done to guide treatment. As with most standards, TJC defines what needs to be done, but not how it is done. Thus, depending on the setting and resources, a comprehensive pain assessment may be done by the nurse, doctor or specialist. A comprehensive assessment may be as simple as the nature, location, intensity of pain and response to treatment; or it may be multidimensional, including the patient's emotional state, its impact on functioning and whether or not the patient is at risk for substance abuse. TJC does not define the details of what constitutes this comprehensive assessment; the institution does. The institution then is accountable to see that all staff and involved professionals know their role and are trained to do it."
"Similarly, there is a requirement to educate all staff and licensed independent practitioners who are involved in pain assessment and its treatment. This extends to all physicians, nurse practitioners, physicians assistants, and psychologists who treat patients with pain. Responding to the question, 'How in-depth does this training need to be?' the standards interpretation group said this, too, was up to each organization to determine. But all who are expected to do it are expected to have been trained to fulfill that role.
"The final caveat is that listservs, blogs, mock reviews, and even journal articles often misinterpret the standards. Sometimes surveyors who are passionate about a topic or a way of doing things may say things that seem prescriptive, but are not part of the standards."