Pain management is agencywide goal

QI project seeks improved pain assessments

At a Missoula, MT, home health agency, the road to better pain management is being walked with careful, deliberate steps.

Dianne Hansen, director of quality improvement for Partners in Home Care, says that as her agency copes with the prospective payment system and a host of other issues, slow and steady is the best way to work on improving pain management without overwhelming staff.

"You really don’t want to try to accomplish this in a short time frame," she advises. "We’ve been at it almost a year, and we feel like we have a good handle on assessment. We’re just beginning pharmaceutical intervention."

"You have to look at what you can realistically accomplish. At the same time, don’t get so intimidated by the whole process that you don’t begin. Just peck away at it, which is what we did. We’ll probably still be working on it this time next year," she adds.

Luckily for Hansen, she has valuable resources at hand. Partners in Home Care has home care and hospice organizations under one roof, and some of the company’s hospice nurses are well-versed in pain issues.

Pain as the fifth vital sign

Missoula also is the home of the Missoula Demonstration Project, an end-of-life initiative that is raising awareness of pain management issues, including teaching hospice agencies how to better assess and treat pain in their patients.

Partners became involved with the project through its hospice component, Hansen says. "They started working with some of our staff in hospice, including some of them in their training and planning. They had a task force called Pain as the Fifth Vital Sign,’ whose major goal was to get facilities to incorporate pain assessment along with vital signs assessment."

She says that after participating in the demonstration project’s training sessions, the agency began to try to institutionalize its pain management practices.

One of the strengths of Partners’ program is that it treats pain management as an agencywide concern. Home health aides are taught to do basic assessments and report back to nurses. Social workers are expected to seek out possible psychosocial causes of pain. Therapists add nonpharmaceutical interventions such as positioning, therapeutic exercise, and massage.

"When we started, that was one of the goals, to treat pain management as an every-discipline issue," Hansen says. "It didn’t belong to any one discipline or any one clinical staff person. Pain management is something that everyone is involved in."

Partners began its program by looking at what institutional standards were in place regarding pain assessment and pain management. "We’re a home care agency that has home health, hospice, IV therapy, private duty, and a case management for the elderly Medicaid waiver program all under the same company," Hansen says. "And we’re finding that each program addressed pain in its own separate way. There weren’t any agencywide pain treatment standards."

There were some programs within different disciplines. "Hospice had some policies; IV therapy had some policies on pain, but most of those were pump-related. We didn’t really have any clear policies or procedures and standards," she says.

In assessing the clinical staff’s skill and knowledge levels, the demonstration project already had laid the groundwork. Hansen says she found that while hospice nurses had a good understanding of pain management in general, home health nurses were less informed and more unsure about their knowledge.

"Home health nurses felt very inadequate in their knowledge level, and there were some nurses who just didn’t understand really basic pain management," Hansen says.

There were other barriers to overcome. Documentation was inconsistent from program to program. Home health’s older computerized documentation system had little flexibility to prompt nurses to ask pain-related questions.

Hansen says there was little comprehensive pain education, except for occasional inservicing. If nurses were unsure of their role, home health aides and social workers were even more in the dark about what they could do to help assess and manage pain.

With so many areas needing improvement, where do you start? For Hansen, the answer was obvious: pain assessment. "If you have a good assessment, even if that nurse doesn’t know how to handle that pain situation, you can go from there," she says.

Throughout fall and early winter 1999, the agency devised a policy for pain assessment. They set forth standards that all staff must meet — to be able to assess pain’s onset and duration, quality, location, and intensity.

Staffers in every discipline must know how to use a 10-point intensity scale to help patients determine the severity of pain. A pain assessment form was developed that could be used consistently throughout the different programs whenever a patient complains about pain.

In addition to intensity levels, the form includes descriptive words that can help patients describe their pain in detail. "It asks what medications have been tried in the past. Have they had any side effects? What effect does pain have on the patient’s functioning?" Hansen explains. "We ask what is the patient’s present pain level? What is their worst pain level? What is their best pain level? What is their goal?"

Wherever possible, Hansen says, the agency added cues in the computerized documentation that prompts nurses to ask about pain. The agency also created logs that patients could use to track their own pain. The logs help nurses document ongoing pain assessment in their clinical notes.

Staff education pays off

The agency used several methods to educate staff, including inservices, a self-instructional unit, and a skills fair, where staffers could model a good pain assessment. Most of the educational work was done by March 2000, Hansen says. Based on a short audit comparing this year’s charts with those completed before the training, the project already is producing results.

"The results are looking really good," she says. "As far as whether they’re recording location and intensity and quality and that kind of thing, those numbers look much better than they did from charts about a year ago. [Before,] we were addressing it only 20%, 30%, 40% of the time, and now we’re addressing it 80% to 90% of the time."

The only area where improvement hasn’t been as dramatic has been in recording patients’ goals regarding pain. Hansen says she’ll follow up with more chart audits later this year.

In beginning to train the staff on pain interventions, Hansen says she didn’t want to bombard them with an overwhelming amount of information. Instead, the agency is developing guidelines that nurses can use to cope with different types of commonly reported pain.

As a backup, the nurses can consult with a committee made up of the agency pharmacist and a number of hospice nurses, Hansen says. If a patient reports mild pain, agency nurses have two or three things to recommend. "For severe pain, these are the oral drugs to begin with. You try that, and monitor the patient’s pain over successive days. If they’re having trouble managing it, [the nurse] could go to the consulting group to try to determine why that regimen isn’t working and make recommendations on some other possible therapies."

The nurses also get information on nondrug therapies to use in conjunction with pharmaceutical options. They are advised on symptom control, such as recommending laxatives when a physician prescribes opiates.

Hansen hopes the guidelines — and the consulting team approach — will take some of the burden off the pharmacist, who is currently fielding a lot of calls from nurses who aren’t sure what to do. As the nurses become more comfortable with the basics, they’ll learn more about pain management, such as converting from one medication to another.

"They’ve sort of had that training before, but they don’t feel comfortable enough with it," Hansen says.

Patients, doctors need help, too

Nurses and other staff aren’t the only ones who need more education on pain issues, Hansen says. For some patients, thinking and communicating in terms of a 10-point intensity scale is difficult. "Even though they can see it, it’s hard for them to put a finger on what their level of pain is," she says. "So you have to do a lot of work with them in making them comfortable using that kind of a scale. That’s probably been the biggest thing we’ve come across."

Eventually, she’d like to have a special educational packet that can be given to every patient who reports pain as a problem, and she says some physicians are just beginning to understand the importance of pain management. "A lot of them still prescribe regimens that are totally ineffective."

She says future educational sessions will deal with how to talk to physicians about recommendations for pain management. Hansen says the secret — no surprise — goes back to a good pain assessment. "You have to have your assessment data to back up what you’re trying to recommend."

Dianne Hansen, Director of Quality Improvement, Partners in Home Care Inc., 500 N. Higgins Ave., Suite 201, Missoula, MT 59802. Telephone: (406) 728-8848. Fax: (406) 327-3727. E-mail: hansend@