You must assess every patient for pain

You’ll need to assess every patient for pain to comply with new pain management standards, stresses Emory Petrack, MD, MPH, chief of the division of pediatric emergency medicine at Rainbow Babies and Children’s Hospital in Cleveland.

"For example, a patient who presents with a fall and a radial fracture will generally have their pain managed if a reduction is required," he says. "However, if a patient is not in obvious pain initially, that patient may not have his or her pain assessed and managed."

The new standards from the Oakbrook Terrace, IL-based Joint Commission on Accreditation of Healthcare Organizations will require that a formal pain assessment be performed for all patients, ideally using a specific pain scale, says Petrack. "The pain will then need to be managed and reassessed during the ED stay," he says.

Surveyors are already asking ED staff whether they have a rating system in mind and if they have already started to use one, says Stuart Shikora, MD, FACEP, a surveyor with the Joint Commission and an ED physician at Mount Diablo Medical Center in Concord, CA. "That shows a plan to take this seriously," he says.

Here are some ways to improve assessment of pain:

Assess pain at discharge.

Most EDs have a space on their forms to document pain during triage, initial assessment, and prior to discharge, says Kathleen Catalano, RN, JD, senior consultant to the Greeley Co., a Marblehead, MA-based health care consulting firm in specializing in regulatory compliance. "The problem is that many fail to document pain at discharge," Catalano says. "The patient may have had a pain score of 10, which is certainly worthy of a comment at discharge."

Ask for specific information about the patient’s pain.

When pain is assessed, the following items should be documented, according to Catalano:

• pain quality;

• location;

• duration;

• frequency;

• measures patient has used before to relieve pain.

Assess for other symptoms.

The new standards require you to assess for all symptoms that might be associated with a disease, condition, or treatment, notes Ann Kobs, MS, RN, president and CEO of Type 1 Solutions, a Fort Myers, FL-based compliance consulting firm specializing in preparation for Joint Commission surveys. "It isn’t just pain," Kobs emphasizes. The standards also include nausea and dyspnea, she says.

Use a variety of pain assessment tools.

Staff must be familiar with a variety of pain tools to meet the needs of all ED patients, Shikora says. "Children and the elderly are both groups where age-appropriate assessment becomes important," he says.

Developmental concerns will need to be taken into account, with different pain scales used for young children, the elderly, and developmentally disabled individuals, notes Petrack. (See the Wong-Baker FACES scale for use with children and developmentally disabled individuals, inserted in this issue.)

How to ask elderly, children

With children, you might need to use certain words when asking about pain, says Petrack. "If you ask a 3-year-old, does that hurt?’ it may mean nothing. Ask the parents what word they use to describe pain. You may need to ask, is that an ouchie?’" Elderly patients may respond more accurately with verbal descriptor scales than numeric rating scales, he adds.

You might need to spend extra time when assessing pain in elderly patients, says Regina Fink, RN, PhD, AOCN, research nurse scientist at the University of Colorado Hospital in Denver. "You also may need to rely on family members to help you interpret the patient’s pain," she says.

Address the needs of non-English speaking patients.

You’ll need a way to assess pain in patients who don’t speak English, says Shikora. "A savvy surveyor would not only look at a plan for pain management, but would also ask you, How would you communicate this to a patient who doesn’t speak your language?’" he explains. "Find ways to assess pain in patients who speak in different languages."

To adequately assess pain in patients who speak a different language, you will need a translator, says Petrack. "You can use a visual tool such as the FACES scale, but you will still need to have someone explain to the patient how to use it," he says.

Assess pain for all patients.

Surveyors are asking staff whether each patient is assessed for pain. At this point, having no documentation of pain assessment and no pain scale would lead to problems if the same were true everywhere in the hospital, says notes Catalano.

Make pain a "fifth vital sign," suggests Susie McBeth, associate director of the Joint Commission’s department of standards. "When you take the patient’s blood pressure and temperature, that is a good time to ask about pain," McBeth suggests.

Unless you have a separate pain assessment form, you’ll need to have a box or space for this documentation on the nursing assessment form, says Shikora. "You need to record the patient’s response to the questions, Do you have pain?’ and If so, how much?’" she says.

Triage and staff nurses need to ask this question routinely and manage pain consistently, he stresses. Pain must be assessed the same way, with the same treatment, for the same condition, every time, says Shikora.

Document reassessment of pain.

In addition to initial assessment and treatment of pain, you’ll also need to show surveyors evidence of reassessment, Shikora says. "For example, if a patient comes in with a pain score of 8 on a scale of 1 to 10 and is given an analgesic, the nurse needs to go back after a reasonable period of time and reassess the pain," he says.

The need to reassess is not based on whether the patient asks for more medicine, Shikora stresses. "You need to take a proactive stance and determine with what frequency you reassess," he says. "Do you go back to assess the patient’s pain every 15 minutes or every hour? Maybe the pain has decreased, but the patient is still uncomfortable, so you need to continue treating the pain."

For more information on assessment of pain in the ED, contact:

Kathleen Catalano, RN, JD, The Greeley Co., 200 Hoods Lane, Marblehead, MA 01945. Telephone: (781) 639-8030. Fax: (781) 639-0085. E-mail: