Pain project brings post-op relief to patients

Better assessment, education raise satisfaction

Ask patients what they fear most about surgery, and they’re likely to mention pain. So when Bay Area Medical Center in Marinette, WI, began a project to improve pain education and control, they wanted to track how satisfied patients were with that aspect of their care.

After changes in preoperative teaching and postoperative medication and more frequent postoperative pain assessment, patients rated the hospital’s ambulatory care unit at 94.1 out of 100 for pain control, compared with a prior rating of 91.9. ("Ambulatory care unit" is Bay Area Medical Center’s name for its post-anesthesia care unit.)

A similar inpatient program showed a leap from the 67th percentile to the 89th percentile when patient satisfaction with pain control was compared nationally with a database of hospitals of a similar size.

Perhaps even more important than the statistical rating was the new staff attitude toward pain management. Nurses now ask patients to rate their pain on a scale of 0 to 10 every time they visit with them after surgery. A rating of 5 or more brings immediate action — either more medication or a call to the patient’s physician. Changes in pain management were based on guidelines from the Agency for Health Care Policy and Research in Rockville, MD. (For ordering information, see sources, p. 40. For more information on pain management, see Same-Day Surgery, July 1996, p. 73.)

The project "changed the way we looked at pain altogether," says Linda Newbury, RN, director of the dialysis and ambulatory care units. "It made us more aware of the patient’s perception of pain.

"Prior to the pain management program, we just asked the patients, and they gave us their impression if they were having pain or not. We had no way to measure the intensity of the pain."

Bay Area Medical Center’s pain management project won recognition from the South Bend, IN-based Press, Ganey Associates, a consulting firm that specializes in patient satisfaction and sponsors "client success story" awards each year. The national comparisons came from Press, Ganey’s database.

Teaching patients to expect relief

Physician support was critical to the quality improvement project to improve post-surgical pain, says Grace Tousignant, RN, the hospital’s risk manager/physician liaison and coordinator of the pain project. Tousignant formed a multidisciplinary quality improvement team that included physicians, nurses, and other members of the surgical staff.

Bolstered by articles from the medical literature and the agency guidelines, the committee’s goal was "to improve the consistency of assessment and management of pain." (For a partial list of articles on pain management after surgery, see selected references at the end of this story.)

For baseline information, Tousignant pulled 50 charts of patients who had undergone inpatient surgery: partial excision of large intestine, hysterectomy, and cholecystectomy. She collected data on seven indicators that were part of the Wisconsin Peer Review Organization’s benchmarking project on pain management.

The ambulatory care unit focused on improving awareness about pain management among physicians, nurses, and patients. Improvements in pain control targeted each phase of the same-day surgery process. Patients now learn about the pain scale during their pre-op instruction, and nurses tell them to expect quick relief in response to reports of pain.

Mars and Tousignant visited surgery department meetings and spoke about the guidelines as well as antiemetics that could be used to moderate side effects from narcotics such as morphine.

"Education and communication is the most important part of this [project]," Tousignant says.

Patients generally receive intravenous narcotics in the recovery room to dull the immediate pain, and they take their first dose of oral medication before discharge from the ambulatory care unit, which is the secondary recovery area.

"In [inpatient care], you always get a second, third, fourth, or fifth try at relieving their pain," says anesthesiologist Anthony Mars, MD. "In the ambulatory care unit, you have to address that pain on an immediate and long-term scale by exposure to the patient for a short period of time."

Managing post-op pain

Giving patients their first dose of oral medication before discharge allows physicians and nurses to determine if it will be effective in controlling the pain, Mars explains, adding that frequent assessment and improved treatment lead to a more successful outcome.

"Other than nausea and vomiting, a common reason for admitting a same-day surgery patient is difficulty with managing their postoperative pain," he says.

One goal of the hospital’s pain management project was to reduce the use of intramuscular injections of Demerol (meperidine) and increase the use of IV morphine. The intramuscular route doesn’t have reliable absorption, Mars says.

The inpatient intramuscular injections dropped from 82% to 33% vs. a comparable rise (18% to 67%) in IV pain medication. (Figures were not available for same-day surgery.) Bay Area Medical Center also sought to reduce the mixing of opioids, which can lead to side effects. The cases in which opioids were not mixed rose from 62% to 70% during the project period.

The hospital also sought to increase the use of patient-controlled anesthesia. That gain was most modest: from 8% to 12%.

Nurses step up pain monitoring

Pain assessment changed dramatically with the project. Now, when nurses ask patients about their pain, it has a greater import. Nurses have received inservice training about the patient’s perception of pain.

They must monitor pain at least three times in the ambulatory care unit: when the patient arrives, a half-hour after arrival, and at discharge. The pain scale ratings are recorded in the nurse’s notes.

In fact, nurses assess pain at every patient encounter to ensure satisfactory pain control, which means monitoring is even more frequent than that, Newbury says.

Despite a more aggressive response to pain, the ambulatory care unit has not seen an appreciable increase in nausea or vomiting, she says. The hospital also revamped its discharge instructions to provide more information about pain control and home care.

Pain is viewed as a vital part of the patient experience — one that nurses and physicians want to minimize as much as possible. "We know if [the pain is] 5 or above, we have to either medicate the patient or contact the physician," Newbury says. "We have to follow through. We can’t just let pain of 5 or above go without dealing with it."

Selected references

Chapman CR, Syrjala KL. "Measurement of Pain." In: Bonica JJ, ed. The Management of Pain. 2nd ed. Philadelphia: Lea and Febiger; 1990, pp. 580-594.

Melzak R, Abbott FV, Zackon W, et al. Pain on a surgical ward: A survey of the duration and intensity of pain and the effectiveness of medication. Pain 1986; 29:67-72.

Seers K. Perceptions of pain. Nursing Times 1987; 83:37-39.

Weis OF, Sriwantakal K, Alloza JL, et al. Attitudes of patients, housestaff, and nurses toward postoperative analgesic care. Anesth Analg 1983; 62:70-74.