A Practitioner's View of New JCAHO Standards on Pain Practice
Diane discusses better pain management as a result of JCAHO partnering with Robert Wood Johnson Foundation
Diane Scheb, RN, MSN, currently serves as the Acute Pain Program Coordinator and a Clinical Nurse Specialist at Sarasota Memorial Hospital in Sarasota, Florida. She directs and manages the clinical activities of the interdisciplinary Acute Pain Service at the hospital. Ms. Scheb is also responsible for the development and implementation of Acute Pain practices to reduce the incidence and severity of Acute Pain in specific patient populations, namely post-surgical, post trauma and palliative care patients. She is a member of the American Pain Society and American Society of Pain Management Nurses. Ms. Scheb earned her Master of Science, Nursing at Andrews University, Michigan and her Bachelor of Science, Nursing at the University of Florida.
Pain.com: Why did the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) partner with the Robert Wood Johnson Foundation to mobilize an effort to promote better pain management?
Ms Scheb: The standards were developed because there is much evidence to suggest that pain is grossly undertreated in the United States, especially in hospitals and other institutional settings. Additionally, unrelieved pain can cause serious physiological, psychological and financial complications to those that endure it.
Despite marvelous advances in both technological and pharmacological therapeutics, as well as an incredible spurt of knowledge on the subject of pain management, pain continues to be under-managed and undertreated.
The standards provide institutions with invaluable tools to develop and promote systems that support quality pain management. They raise awareness of pain for patients, physicians and staff.
Pain.com: When do the new standards take effect and who is affected by them?
Ms Scheb: The JCAHO Pain Standards went into effect January 1st, 2001. The standards effect all patients in hospitals, nursing homes and clinics.
As Dennis O'Leary, President of JCAHO, is quoted in the Washington Post as saying, "This is the first time that we have developed standards for a symptom, but pain is very much a mainstream problem. Millions of people are affected by it."
Pain.com: Specifically, what do the Pain Standards require institutions (i.e., hospitals) to do?
Ms Scheb: In general, the Joint Commission's new standards require organizations to:
· Recognize the right of patients to appropriate assessment and management of their pain.
· Screen all patients for pain and perform a more comprehensive pain assessment if pain is indicated.
· Educate patients and their families about the importance of effective pain management.
· Educate relevant providers and ensure staff competency in pain assessment and management.
· Establish policies and procedures that support the appropriate prescription or ordering of effective pain medications.
· Address patient needs for symptom management in the discharge planning process.
· Collect data to monitor the appropriateness and effectiveness of pain management.
Pain.com: Is there a certain standard that is pivotal and foundational to success? It seems like such a lot of new information to be put in place at once.
Ms Scheb: In the Patient Rights and Organization Ethics chapter there is a standard that reads, "Patients have a right to appropriate assessment and management of pain." This standard forces the healthcare organization to plan, support and coordinate activities to assure that pain of all patients is recognized, asked about and treated appropriately. It includes initial assessment and regular reassessment of pain. It includes pain management education for both patient, families and staff. It encourages hospitals to promote pain as the fifth vital sign.
In my own hospital experience, we had to put a "pain assessment strategy" in place whereby pain is assessed every four (4) hours. You can't treat what you don't know about. Fancy PCA and Epidural protocols are of lesser value if every patient is not being assessed in the same way.
Pain.com: How does the patient benefit from the standards and better pain management?
Ms Scheb: Unrelieved pain has many negative consequences. Physiologically, a surgical patient in pain cannot comply with the plan of care that usually promotes early mobility with coughing and deep breathing. This can lead to pneumonia and the formation of blood clots. Psychologically, acute pain can be emotionally traumatizing; chronic consistent pain can lead to depression.
When pain is relieved, there are less complications and sometimes a shorter length of stay because patient outcomes are better. In addition, the whole experience is better and more pleasant for the patient. It allows the patient to focus on the job of getting well instead of muscling through the hurt.
Pain.com: How does an organization go about putting the standards in place?
Ms Scheb: First of all, you have to learn about them! There are many resources out there to do this. One excellent example is the "2001 Joint Commission Leadership Summit on Pain Management."
Joint Commission Resources will present the Second Annual Joint Commission Leadership Summit on Pain Management twice in 2001 - June 25 and 26 in Phoenix, and September 20 and 21 in Atlanta. This year's Summit is expanded to one and one-half days to allow for more in-depth coverage of pain management issues including:
· Proven strategies for building institutional commitment to pain management.
· Precise examples of implementation of JCAHO standards as they relate to special populations and issues.
· Validated methods for measuring, monitoring and tracking outcomes to gauge effectiveness of programs.
· Efficient and effective ways to define and assess the competency of clinicians.
Conference brochures are available at www/jcrinc.com/natlevnts.htm or call the Customer Service Center at (630) 792-5800 for more information.
Pain.com: As an organization prepares to meet JCAHO pain standards, what disciplines, what level (i.e., physician, administration, staff nurse, educator), what degree (full-time, part-time. . . ) and for how long are resources being allocated?
Ms Scheb: Most institutions have put a multidisciplinary committee composed of physicians, hospital leadership, nurses and pharmacists together to develop and implement the strategies. This committee may meet monthly to oversee the process. Even the standard "examples of implementation" suggests that a dedicated "pain relief specialist" be put in place in institutions. He or she will need a multidisciplinary army to help with development and implementation.
It has been my experience that, once the foundation is in place (i.e., initial and regular reassessment of pain, education of patient and nursing staff), it soon becomes obvious that there are specific patient populations that are really hurting. Pain teams comprised of nurses and pharmacists are springing up all over the country. Some are supported by the hospital, some are anesthesia driven. These disciplines and the primary nurse can enhance the care of the patient by helping to manage the patient's pain.
Finally, Pain Resource Nurse programs are also in place in many hospitals. In my hospital, we recently trained 55 expert nurses in some advanced protocols. They are also responsible for putting the JCAHO standards in place on their nursing unit under my direction. They are an enthusiastic and excited group of nurses and find managing pain professionally rewarding.
Pain.com: It seems like meeting these new standards will require more than just a change in policy and procedure. In some cases, attitudes and culture will have to be adjusted. How will this be accomplished?
Ms Scheb: Very true, changing attitudes and culture can be difficult. Ongoing education as well as pointing out to physicians and staff how positive patient outcomes correlate to good pain practices slowly help to make the paradigm shift.
Example 1: "Dr So & So, your AAA patient was so much easier to ambulate with the epidural for pain management in place. Could we try it again on the next one?"
Example 2: "Yes, the chart did state that this patient may be a drug seeker, but good for you for recognizing that he has a right to have his pain managed."
Example 3: "That patient's pain was beautifully managed and he gave us high marks on the patient satisfaction survey."
Pain.com: Does the Joint Commission really require organizations to measure the quality of their pain management? How is this accomplished?
Ms Scheb: The chapter on Organization Performance has a standard that states that the organization collects data to monitor performance. Data that the organization considers for collection to monitor performance include the appropriateness and effectiveness of pain management.
To this end, organizations are required to measure, monitor and track outcomes to gauge the effectiveness of pain management. Organizations need to be able to show relevant data that pain management is tracked and measured.
We have two methods for doing this:
Method #1 - An internal "concurrent chart review", whereby a nurse reviews one chart per month to see if pain is assessed every four (4) hours; and
Method #2 - An external patient satisfaction survey, whereby the satisfaction with pain control is measured monthly via patient satisfaction survey (Press Ganey).
Pain.com: We have heard that patients are actually "satisfied" with experiencing a lot of pain. How can this be?
Ms Scheb: Patients appear to be quite satisfied despite high levels of pain. Some patients believe that pain is to be expected, don't realize that their pain can be treated, or don't want to "bother" their care providers. Satisfaction can be related to patients' perceptions of the service experience and to their perceived control over care decisions rather than the severity of their pain.
Finally, some patients think grinning and bearing it is the norm and a part of a whole culture of attitudes and life experience.
It is a privilege to show them that it does not have to be that way and it is ok to be comfortable!
Pain.com: If someone is about to have surgery, what can he or she do to educate himself about state of the art pain management for that particular surgery?
Ms Scheb: Check out Pain.com!!!
» Return To Expert Interviews
|
|
