New pain management standards: 4 questions surveyors are asking

Joint Commission surveyors want to know your plan to manage pain

Are you ready to answer questions about how pain is assessed and treated for patients in your ED? Can you produce documentation that shows how pain was managed for any given patient? You’ll need to do both these things to comply with new pain management standards from the Oakbrook Terrace, IL-based Joint Commission on Accreditation of Healthcare Organizations. (For information on how to view the standards, see resource box, p. 75.)

The new standards address six broad areas, says Emory Petrack, MD, MPH, chief of the division of pediatric emergency medicine at Rainbow Babies and Children’s Hospital in Cleveland. These are assessment, continuum of care, improving organization performance, patient rights, care of patients, and education. (See related stories on assessment of pain, p. 77; four steps to manage severe pain, p. 80; and follow-up for pain management, p. 79.)

You must be ready to answer questions in the following four areas, according to Petrack:

1. Are the tools used for pain assessment developmentally appropriate for different age groups?

2. Have appropriate policies and procedures for pain assessment and management been established? Are they being followed? How are staff being trained, and how are competencies being demonstrated?

3. Are patients and families educated in issues related to pain management?

4. Do patients know their rights? How do they know them? (See story for more information about questions surveyors are asking, p. 76.)

There is tremendous variability in how patients presenting with painful conditions are assessed and managed, notes Petrack. "A major goal of these standards is to ensure that a patient’s pain is appropriately and consistently addressed throughout the hospital," he says.

Spotlight on the ED

The ED will be a major area of focus for surveyors, predicts Anne Llewellyn, RNC, BPSHSA, CCM, CRRN, CEAC, owner of Professional Resources In Management Education, a health care educational and consulting company in Miramar, FL.

"The ED is a key area where many patients come to seek treatment for pain," Llewellyn says.

The new standards create special challenges for EDs, notes Susie McBeth, associate director of the Joint Commission’s Department of Standards. "Unlike other departments, EDs handle all sorts of pain, both acute and chronic," McBeth says. "They also see all types of patients, including infants, children, and the elderly. All of those are handled differently, with different screening tools used."

Complying with the new standards will take significant work and leadership by the ED management team, says Petrack. "That said, there is great potential to improve our management of painful illnesses and injuries, and in so doing, yield better emergency care to the patients we serve," he says.

Here are ways to comply with the new pain management standards:

Implement a quality improvement program.

Develop a quality improvement component for pain management, advises Petrack. "The successes and failures of pain assessment and management will need to be formally examined and opportunities for improvement identified," he says.

Have physicians participate in the planning process.

Involve ED physicians in the overall planning of your pain management process, says Stuart Shikora, MD, FACEP, a surveyor with the Joint Commission and an ED physician at Mount Diablo Medical Center in Concord, CA.

A pain management strategy cannot be created for the ED by consultants, administrators, or nursing staff, says Shikora. Physicians need to help develop protocols for interventions and tools to use for specific types of pain, he explains.

Tie pain management in with ORYX.

If your hospital chooses pain management as a parameter to measure for the Joint Commission’s ORYX initiative, that presents an opportunity for your ED, says Shikora. "The ED contribution could be a simple three-point study looking at whether the patient’s painful condition was assessed, measures were taken, and results were reassessed." (For more information about ORYX, see ED Management, April 2000, p. 37.)

Consider alternative ways to manage the pain of substance abusers.

ED patients with substance-related disorders may request medication to manage their pain, notes McBeth. "This creates an ethical dilemma, since even if a patient is a drug seeker, that doesn’t preclude them from having pain. Their pain still needs to be treated," she says.

If you suspect a patient is a drug seeker, explore nonpharmacological interventions such as distraction, massage, heat, acupuncture, physical therapy, or behavioral therapies, she suggests.

Form a process improvement team.

Have a multidisciplinary team look at issues and address standards to improve consistency of pain management facilitywide, stresses Regina Fink, RN, PhD, AOCN, research nurse scientist at the University of Colorado Hospital in Denver. At the hospital, a team of physicians, nurses, and pharmacists has formed five subcommittees to address pain assessment, staff education, patient outcomes, patient education, and policies and procedures, she reports.

Use protocols.

Collaborate with ED staff to set policy and standards that delineate specifically how pain will be assessed, treated, and reassessed, advises Petrack. (See protocols for EMLA Cream in the ED and Renal Colic Pain, inserted in this issue.)

"I would highly recommend that EDs use protocols to comply with the new standards," says McBeth. The American Pain Society and the American Academy of Pain Medicine, both based in Glenview, IL, have developed pain management guidelines that can be used to develop ED protocols, she notes. (See resources box, below, for information on how to obtain copies of the guidelines.)

Use cards for pain management.

At the University of Colorado Hospital’s ED, double-sided cards with information on pain assessment and analgesic use are handed out to nurses at orientation. (See Pain Assessment Guide, p. 74, and Analgesic Reference Guide, enclosed in this issue.) The cards help nurses know which medications to use and assess pain consistently, says Fink. The guide includes a 0-10 Numeric Pain Intensity Scale (0 = no pain, 10 = worst possible) and a Wong-Baker Faces Pain Rating Scale that ranges from a smiling face (0, no hurt) to a crying face (5, hurts worst).

Educate yourself and your staff about new approaches.

You need to conduct appropriate training of nurses and physicians so the standards can be implemented, says Petrack.

A good first step is to perform a literature search in order to share research on current philosophies and techniques of pain management with medical and nursing staff, suggests 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.

Education of medical staff is key, she emphasizes. "Until they understand current methodologies, no significant changes can be made, and physicians will still be prescribing Demerol every three hours," Kobs says.

Many of the pharmaceutical companies that specialize in pain medications will be conducting CE programs to help health care professionals better understand this issue, Llewellyn notes. "This will be a way that professionals can learn about the newer techniques that are now available to treat pain effectively," she says.


• The complete new pain management standards of the Oakbrook Terrace, IL-based Joint Commission on Accreditation of Healthcare Organizations are currently available on the Joint Commission’s Web site (www. Double-click on "For Health Care Organizations and Professionals" on the main page. On the next page, click on "Standards" in the top bar. This will take you to the standards page, which includes a link to the pain management standards. Manuals that include the standards can be purchased by calling the Joint Commission’s Customer Service Center at (630) 792-5800 between 8 a.m. and 5 p.m. central time on weekdays.

• Single copies of pain management guidelines titled Quality Improvement Guidelines for the Treatment of Acute Pain and Cancer are available from the American Pain Society at no cost. To request a copy, contact: American Pain Society, 4700 W. Lake Ave., Glenview, IL 60025. Telephone: (847) 375-4715. Fax: (847) 375-4777. E-mail: Web site:

• Single copies of consensus statements on the Basic Principles of Ethics for the Practice of Pain Medicine, The Necessity of Early Evaluation of the Chronic Pain Patient, and Use of Opioids for Treatment of Chronic Pain are available at no charge from the American Academy of Pain Medicine. Brochures on Acute Pain and Cancer Pain, A Brief Guide to Pain Medicine, and A Patient’s Guide to Pain Medicines are available in packs of 50 for $20 plus $3 shipping and handling per order. Single copies of brochures are available at no charge. For more information, contact: American Academy of Pain Medicine, 4700 W. Lake Ave., Glenview, IL 60025. Telephone: (847) 375-4731. Fax: (847) 375-6331. E-mail: aapm@ Web: