April 27, 2001

Care Improvement Committee focuses on pain management

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Care Improvement Committee focuses on pain management

As Vanderbilt takes strides to improve management of inpatient pain, the staff and faculty members leading the way say there’s significant opportunity for improvement. The people at JCAHO (Joint Commission on Accreditation of Healthcare Organizations) would likely agree, having recently made improved pain management a top priority for the nation’s health care system.

The Vanderbilt effort is being led by the VMG Care Improvement Committee, and by the nurses who are monitoring pain as a fifth vital sign (along with heart beat, body temperature, respiration and blood pressure).

“It seemed to me that patients here received good pain management,” said Dr. Lonnie S. Burnett, Frances and John C. Burch Professor in Obstetrics and Gynecology and chair of the VMG Care Improvement Committee. “Members of the committee persuaded me that may not be the case. I began by asking each patient during rounds to tell me about her pain. I was amazed to hear patients frequently say they had a lot of pain. And I was embarrassed by how little I knew about this aspect of care. I’m guessing this would be true for other doctors. You’re not a bad doctor if you don’t know much about pain, but you are if you don’t try to do better.

“This has made a striking difference in how I relate to patients,” Burnett recently told a meeting of the VMG board of directors.

These days, if he doesn’t establish pain control within a few hours, Burnett calls the acute pain service for a consult. Burnett says resident physicians he works with also regularly ask patients about their pain.

Burnett receives letters of thanks from patients specifically regarding their pain control. He recalls a recent patient with a history of pulmonary embolism who, despite every precaution, developed a dangerous embolism which ultimately ended without causing harm. When she returned for a follow up, Burnett expected a strong dose of criticism. Instead, she talked about how well her pain was controlled. The patient also said she has recommended Vanderbilt to her friends and family.

Catch pain before it starts

“Across the hospital, we’re probably pretty good at pain intervention, but not so good at pain management, which includes anticipating and heading off pain before it starts,” said Irene Hatcher, a consultant with the office of case management and a member of the committee. Burnett said many inpatients may be reluctant to voice their pain and ask for medication. Indeed, studies have shown that many inpatients don’t know how to access pain relief measures. “Our pain management at Vanderbilt is clearly patchy,” Burnett said. “We consider we’ve done well when we give a narcotic that successfully reduces pain. What we commonly don’t fully appreciate are the important benefits that come from never allowing pain to reach significant levels in the first place.”

“If the patient is in pain, we’ve lost the opportunity to maintain his or her pain control, and we’re in the position of having to catch up,” said Phil Johnston, a clinical pharmacist and consultant to the committee.

If nausea is going to occur with a narcotic, it typically happens as the drug begins working, then fades away as the drug reaches full strength in the body. If you give a patient a narcotic, Johnston says to give it around the clock rather than “as needed.” This not only makes for continuous pain control, but also avoids repeatedly subjecting a patient to the common side effect of nausea.

Four steps

Burnett stressed that pain management is a team effort. Focusing on acute postoperative pain, the committee developed four proposals, all of which have been approved by the Vice-Chancellor’s Advisory Council, the VMG board of directors and the Vanderbilt University Hospital Medical Board. The proposals are:

Patient pain questionnaire – Prior to discharge all inpatients, or a representative sample, will receive a questionnaire on how well their pain was managed during their admission. Patients will answer questions such as whether they were asked about their pain, and whether their doctor was attentive to their pain. The questionnaire has been tested in orthopedics, urology and gynecology, and the final version will be introduced across the hospital sometime this summer. Results will not be reported by physician, but rather by hospital unit and by service.

Pain quiz for docs and nurses – All attendings, residents, medical students and nurses will be asked to take a short multiple-choice quiz about pain management. The quiz has been tested on pharmacists and various doctors and will be given sometime this summer.

Continuing education – Findings from the Vanderbilt pain quiz and national guidelines on pain management will be used to shape continuing education offerings for Vanderbilt doctors and nurses. The learning center and the office of continuing medical education will help develop educational materials. The office of continuing medical education will look into putting these materials on the Web, and possibly marketing the instruction module to other institutions.

Morbidity and mortality conference – At the division or department level, attendings, residents and medical students hold periodic conferences to review deaths and unexpected adverse responses to care. Nursing documentation in the patient chart allows identification of poorly managed pain. Burnett and the committee have proposed that poorly managed pain become part of this conference.

The committee is also compiling a list of in-house pain experts, and is exploring how pain management tips and guidelines might be incorporated into the hospital’s electronic order entry system (WizOrder). In addition, the committee has proposed adding “appropriate assessment and management of pain” to the list of VUMC patient rights.

The fifth vital sign

On a scale to 10, a pain level of five or above is apt to interfere with appetite, sleep and other aspects of daily living.

For inpatients, many nurses have begun documenting the following in the chart: (1) whether they advised the patient on admission about asking for pain relief; (2) the patient’s pain level on a scale to 10 (as reported by the patient), documented at least once per shift; (3) the outcome of any pain intervention (pain level as reported by the patient); and (4) whether the nurse advised the patient about post discharge comfort measures. These notes are required for all inpatients, regardless of whether they’re receiving pain meds.

It turns out that many nurses at VUH are failing to document pain. In the last month measured, 42 percent of VUH patients (adult and pediatric) had their pain assessed and the level recorded at least twice a day. This was down from a high of 78 percent that had been reached several months previously.

Hatcher said documentation forms will be upgraded soon to support improved practice and documentation. Also, a section on pain is being added to the admission history taken by nurses; this will include the patient’s past experience with pain and what has worked to manage that pain.

For more information on activities of the VMG Care Improvement Committee, contact any of the following by email or phone: Dr. Lonnie Burnett (2-7358), Phil Johnston (2-2374), Nancy Wells (2-6184), Irene Hatcher (3-2680).