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QI project cuts patients’ chronic pain dramatically
Facility earns Codman Award from JCAHO
A quality improvement project at a Michigan long-term care facility resulted in a decrease in the prevalence of chronic pain among its residents from 33% in March 2000 to 18% currently.
The reduction is even more significant — given that the assessment of an individual’s pain is highly complex, particularly among the elderly, who may experience cognitive or communication difficulties.
The Joint Commission on Accreditation of Healthcare Organizations recently awarded Marwood Nursing & Rehab in Port Huron, MI, the Ernest A. Codman Award that recognizes excellence in the use of outcomes measurement by health care organizations to achieve improvements in the quality and safety of health care.
Marwood’s nursing team focused on the potential benefits of better pain management by developing a resident assessment protocol tool consistent with the Minimum Data Set requirements of the Centers for Medicare & Medicaid Services.
Individual resident care plans then were revised to address the specific pain issues identified by using the new tool, in addition to other pain assessment and medication management tools developed through the initiative.
Forming the pain management teams
One of the first steps was the formation of two pain management teams. The first, which worked together on the overall program, comprised 30 members from all disciplines, including Marwood’s medical director.
Suzanne Walker, RN, unit coordinator and leader of the clinical pain management team, says the large size of the team and varied backgrounds proved to be helpful.
The members had different life experiences and professional backgrounds, so they were able to develop better solutions, she points out.
Another important component of the program was the revision of forms that now call for more specific information about the physical and emotional conditions of residents being assessed.
Originally built as a 50-bed nursing home in 1963, today Marwood Nursing & Rehab is a 240-bed not-for-profit, skilled nursing facility that has been affiliated with Port Huron Hospital since 1987.
The focus on pain management began in 1999, Walker says. The first efforts involved education of staff, residents, and family. Using research showing that pain is not a normal part of aging and often not a result of the patient’s diagnosis, Walker and her colleagues sought to change the way people look at pain.
"The cause could be spiritual, psychosocial, or emotional. It’s broader than we really thought it was," she says. "We educated our housekeeping staff, maintenance, office staff, and all nonnursing staff in basic pain assessment. So a housekeeper who goes into a patient room to sweep can listen when the patient says she has a headache, or can notice that she is different from yesterday. Maybe the housekeeper can’t explain why they’re different, but they know something is wrong."
That nonclinical staffer is expected to report the observation to a nurse or physician, who can make a more thorough assessment. The idea is to empower the ancillary staff by educating them, Walker says, and the staff take it very seriously.
"They know it’s not just the nurse’s job. It’s everybody’s job," she says. "It’s the job of the activity person walking down the hall who sees a resident who is restless or agitated. They know it’s their responsibility to notify the nursing staff."
This type of shared responsibility didn’t come easily, Walker says. It never would have worked previously, because the nonclinical staff didn’t know what to look for, and the nursing staff didn’t respect their concerns if they did speak up. But now, she says, the ancillary staff feel confident while still knowing their limitations, and the nursing staff know that everyone has been trained in the basics of recognizing pain.
And the education didn’t stop with the ancillary staff. There still was plenty to teach the nurses about pain management, she says.
As in most health care settings, medication always had been the No. 1 defense, but now Marwood looks for nonpharmacological approaches — back rubs, quiet environments, soft music, music therapy, pet therapy, or just someone to sit and talk with the resident.
Walker and her colleagues used proven quality improvement processes for the project, first collecting data and conducting audits to get baseline information.
One immediate revelation was that the facility’s documentation could be better. The existing documentation was "fair, but it wasn’t great," she says, and made follow-up difficult. The pain management teams also quickly saw the need to improve forms.
"There were lots of form changes, and the input on form changes came from the nursing staff because they use the forms," she says. "Then we went back and audited it to see if the changes were effective."
Baseline data collection started with 25 residents who were monitored over a two-year period. The QI team also did a staff survey. The survey revealed that staff were very frustrated over poor communication related to pain management.
"We had complaints that some people would hear of a resident’s pain and blow it off, saying an 85-year-old patient is going to be in pain," Walker says. "That clearly had to change."
In addition to the overall pain management team with 30 members, Marwood developed a clinical pain management team with two registered nurses, a social worker, and a pastor. Staff can make a referral to the team, which Walker heads, if they feel frustrated with their own attempts to help a resident in pain.
If a staff member has notified clinical staff but still thinks the resident is not being helped, he or she can contact the pain management team for help. Then the team will conduct a chart audit, review the case history, and look at what the current recommended practices are and what the nurses are doing. Then the team makes recommendations to the nurses and physicians for changes that might be needed to manage the person’s pain.
The QI project has led to a much more collaborative atmosphere at the facility, she says. It used to be that if the physician made a decision, the nurse followed instructions and the family went along with it. Now, Walker says, staff may decide with the family what they want for the resident, and go to the physician with their suggestion.
The results are convincing. When the program first started in 2000, the prevalence of pain was 33%. Now it’s at 18%. The effort to better control pain had a direct impact on the facility’s quality indicators — weight loss, decline in activities of daily living activity, behaviors affecting others, and decrease in range of motion. Walker found that as pain issues were handled better, residents ate better and weight became more stable. Residents got out of bed and felt better.
One of the best aspects of the project was that it didn’t cost much. she says that when Marwood presented the project description to the Joint Commission, the accrediting body didn’t understand Marwood’s claim that it had an open-ended budget.
"What that meant was that our biggest expense was time, and we were willing to put in a much time as it needed," Walker says. "We didn’t have to go out and buy equipment. We had to invest time to research and educate our staff, family, and doctors, so everyone has the same focus and the same information. That was our biggest expense, our time, and the administration made it easy to spend time on this."
The administration approved multiple teleconferences for staff, and the pain management teams used the in-house pharmacist as a key resource.
Walker offers this advice for any health care provider seeking to improve pain management and affect quality indicators: