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Complying with TJC pain management standards
Handling reassessments, other challenges
Have you revisited your pain policy? Are you auditing compliance? How will you fare when Joint Commission surveyors come to your facility? Hospital Peer Review spoke with three institutions about the challenges they faced, the interventions they made, and the successes they have seen.
Debra B. Gordon, RN-BC, MS, ACNS-BC, FAAN, senior clinical nurse specialist at the University of Wisconsin Hospital and Clinics (UWHC) in Madison, was involved with the development of The Joint Commission standards on pain management, which went into effect in 2001.
She says a few years after the standards were implemented, surveyors visiting UWHC cited the system with a request for improvement on documenting pain reassessments an area experts say hospitals continue to struggle with, specifically the time frame of when to document a reassessment. Gordon says she had data showing that assessments and reassessments were being done, but the surveyor said, "You have a lot of numbers, but I can't tell what's happening."
"Unfortunately at the time, there was not a lot of [literature] about the minimum time and elements for reassessment or documentation." And The Joint Commission does not specify when reassessments must be done; it only says that they be recorded in a way that facilitates regular reassessments.
"So we developed a pretty ideal policy like a lot of people have, which is [documentation of reassessment at] 30 and 60 minutes. If you read a textbook, you think that's the peak effect, that's when the patient is most vulnerable for side effects, and that's when I should know whether they've got relief or not."
But about a month ago, several changes were made to the policy. Requiring reassessment at specified intervals seemed to "actually be starting to drive staff away from documenting that they're even doing anything because then they're required to come back in 30 and 60 minutes and it's a burden and it's just too hard to do," Gordon says. Nurses said they were constantly reassessing pain; the problem was the work burden of documenting it. Another problem, Gordon says, is that many people are confused about the difference between screening for pain, assessing it when it's present, and then reassessing it.
In response, the policy was changed to require nurses to screen for pain at least once every 24 hours. If pain is present, nurses assess it. If the patient has received treatment for pain, nurses must reassess and document at a minimum of three times within 24 hours.
The hospital uses a variety of scales, "and I think that is certainly identified in The Joint Commission standards intent. That you need to have a number that is both developmentally and cognitively appropriate." They use scales in different languages, the FACES scale, preverbal scale and scales for cognitively impaired, nonverbal adults. The system created its own preverbal scale for pediatric patients or children or adults who can't self-report.
Gordon says another area that's caused confusion among hospitals is the standard versus what surveyors were actually telling hospitals to do. For instance, surveyors were telling hospitals to tie PRN range orders with the patient's numeric pain rating.
"But if you look at the original standards, the intent of the standards, they were that we assess pain in all people; that we respect rights to appropriate assessment and treatment; that we educate patients, providers, and families; that we do some quality monitoring. That's what it said. It didn't say you have to give morphine if the pain is 10 or you have to give 5 milligrams if the pain rating is a certain thing. That was all a misinterpretation," and a dangerous thing to do, she says.
Along with the American Pain Society, Gordon co-authored a consensus statement about suggestions on ordering explicit as-needed orders. (See http://www.ampainsoc.org/pub/bulletin/jul04/consensus1.htm.) "All rules are double-edged swords. That doesn't fit. You cannot cookbook pain treatment. It's dangerous. My mild pain isn't the same as yours. And how I respond to morphine isn't the way you respond," she says.
Reassessment time lines
Staff at Altru Health System in Grand Forks, ND, also had to reassess their pain reassessment policy. Janelle Holth, RN, BSN, regulatory compliance coordinator, says through tracers and work with a consultant, the hospital found "that we had kind of set ourselves up to fail through our pain policy in that we associated times, especially with reassessments. So we took a hard look at that policy and really trimmed it down simply to address how we assess pain, when we do, and how we have that comprehensive assessment initially," removing time frames on documentation of pain reassessments. The hospital does monthly audits on pain documentation "looking to make sure if a pain medication has been administered to see when that reassessment was done and was it effective and was there communication with the physician and did they get new orders if need be," she says.
Staff at University Medical Center at Princeton also were having trouble complying with the policy on reassessment time lines. So they began to look at barriers, says Karyn Book, MSN RN CLSSGB, professional practice administrator. One thing they found was oftentimes a patient would be off the floor at the time of reassessment.
Working with IT, nurses now have 60 minutes post-intervention to complete a reassessment, and the computer system is set to trigger the nurse at 30 minutes post-intervention as a reminder. Nurses have the option to document that the patient is not on the floor. The computer system mirrors the policy created and uses drop-down menus rather than free text fields to trigger nurses to include everything. Questions include things such as: Did you ask the patient about pain? What kind of pain assessment did you use the numeric scale, the FACES scale, the FLACC scale? Did you ask about the location, duration, and pattern of pain? Is it constant?
In the hospital's last survey, The Joint Commission commended the hospital's documentation policy for going beyond by including patients' perception of pain and their functional level. If patients didn't meet the functional level upon reassessment, "then we went further, and said, 'OK, what do we do? We know your pain is supposed to be at 3, but it's still at 5. Did you call the physician? Did you offer any comfort measures?' [TJC] liked that we went above and beyond," Book says.
TJC, she says, likes to see that you address what the patient needs to be at a functional level and what you do to get them there. They also focused on pain in post-op patients and maternity patients, Book says.
Holth says another goal was to have pain tools for any patient population. Now, they use a total of seven scales, including a scale for nonverbal patients. All the hospitals interviewed say using a scale for nonverbal or cognitively impaired patients is essential.