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Staff treats pain as fifth vital sign
United Home Health Services Inc. of Canton, MI, has been involved with the Michigan Cancer Pain Initiative expressly for the purpose of having access to educational materials and assessment tools related to pain management.
"Pain management should be something that’s considered essential at every level of your organization, from the administrator down to the home health aide," says Linda Mlynarczyk, BSN, RNsC, clinical director of the hospital-affiliated, mid-sized, freestanding agency that serves western Michigan.
The agency is committed to improving clinician pain management and assessment and has made a variety of changes that hopefully will result in better pain outcomes, Mlynarczyk says. Here is a quick look at the agency’s activities:
1. Attend educational sessions.
Since the agency is part of the pain initiative, United Home Health representatives were invited to attend an educational conference that featured experts on pain assessment and management.
"We were very impressed with the presentation that included a variety of experts who offered their opinions about the status of pain control and issues and problems with pain control, including education of physicians," says Penny Rhein, BSN, RNC, agency vice president and the 1999-2001 president of the Michigan Home Health Association in Okemos.
The educational conference addressed
nurse education and how to train nurses to communicate the needs of patients and make recommendations regarding pain management to physicians, Rhein adds.
"As a result of this education you could work in good partnerships with physicians and come up with a better pain program for your patients," she says.
2. Form a pain management work group.
After Mlynarczyk and other representatives attended the pain initiative workshop in Michigan held earlier this year they formed a multidisciplinary group to plan how the agency could improve its pain assessment and management.
The work group included Mlynarczyk, Rhein, a nursing supervisor, a home health aide coordinator, three staff nurses, a physical therapist, a social worker, and a home health aide.
Mlynarczyk, Rhein, and two other staff members who attended the pain conference met separately to outline a work plan, develop an auditing tool, and presented these to the work group.
Chart audit results encouraging
3. Conduct chart audit and analyze results.
"In the first group meeting, we spent two hours working on a chart audit and pulled at random 26 patient records from January through June 1, 2001," Mlynarczyk says.
"Then we broke into groups to audit these records and see how well we currently are assessing patient pain, how well it’s controlled, and how well we are documenting it throughout the patient’s care," she adds. "We were very productive, and everyone was motivated."
The audit results were encouraging. The agency, prior to joining the pain initiative, had made some changes to pain management policies and documentation based on the new pain management standards of the Joint Commission on Accreditation of Healthcare Organizations of Oakbrook Terrace, IL.
"We found that as an agency, we’ve really heightened our awareness of pain management prior to becoming involved with this initiative," Mlynarczyk says.
But there was room for improvement.
"We were noticing at the group chart audit, we held that although the documentation was good and the patient’s overall pain management seemed to be a priority with the staff, our documentation was not consistent," Mlynarczyk explains. "It did not lend itself to cueing staff on every visit and it was not consistently documented on every visit by every discipline."
4. Make revisions and refine improvements.
At a second meeting of the work group, the group broke up into pairs of people to make revisions to the pain documentation to encourage staff to assess pain at each visit.
They made minor revisions to each of the staffing notes and some additional revisions to improve consistency of documentation.
Changes include adding additional cues for nurses to assess pain and making sure that the pain scale is consistent with other parts of the documentation, Rhein says.
Also, at the top of each nursing note there is a new space for pain, as this is now considered the "fifth vital sign" that must be checked at each patient visit.
"We also will create a clinical pathway to be used for the patient whose primary focus is a pain control issue," Mlynarczyk says. "And we’ll put together a packet for that type of patient so that the nurse or therapist will have the entire packet of materials to use with that patient’s care management."
Pain management now more consistent
5. Provide staff education.
Staff education was easier with the various teaching and training tools provided by the pain initiative project.
One of those resources was a set of video training modules, which are each 15 minutes long and include discussion questions and a post-test," Mlynarczyk says. "At every staff meeting, we show one of those videos."
The videos and other presentations about pain management have been well-received by the staff, Rhein notes. For example, staff already have a greater awareness of consistently assessing patients’ pain, Mlynarczyk says.
"It wasn’t consistent before, and if the nurse found the patient in pain on one visit, the nurse might not remember to assess it on the next visit unless the patient brought it up first," she adds.
Consistency has definitely improved, she says. "From our preliminary findings, it looks like they have a pretty good understanding of how to do it and what needs to be done."