Maybe you’re choking back elated tears at a wedding, or your chest feels absolutely aglow as you enjoy a smoldering sunrise. Or it’s fear—the kind that makes your heart sprint—as a car swerves off course and speeds at you head-on.
Or, you find yourself grimacing in pain in a hospital bed.
If someone interrupted you at the wedding, as that sun inched higher, as the car came toward you, or in your hospital bed, would you have the wherewithal to verbalize those abstract—yet undeniably real—feelings happening within you? What if someone asked, How’s your joy, your fear? Your pain?
How do we begin to answer? How can we talk about how much and how exactly we’re hurting, so caregivers can appropriately treat the pain? A team at Strong Memorial is taking a close look at these slippery but important issues—which absolutely hinge on good communication.
The Problem of Measuring Pain
Since pain is individual, measuring it is by nature imprecise—but hospitals try. Needless to say, we want to keep our patients comfortable, but we’re also concerned with our HCAHPS scores, which tie back to our good reputation and ensure that we recoup performance-based funding.
The HCAHPS (Hospital Consumer Assessment of Healthcare Providers and Systems) surveys capture patients’ takes on their recent hospital visits. In this national, standardized, publicly reported survey of the patient experience, two of the 27 questions revolve specifically around pain. They are, “During this hospital stay, how often was your pain well controlled?,” and “During this hospital stay, how often did the hospital staff do everything they could to help you with your pain?”
The results of these responses combine to yield the hospital’s composite score in the domain of pain management, and that score is an important basis of comparison between hospitals. As you might know, credit is granted only for “Always” responses (the other choices are “Never,” “Sometimes,” and “Usually”). And, as Kimberly Ziegler, Clinical Nurse Specialist for Adult Medical Surgical Nursing, pointed out, “If a patient has a single bad experience in the hospital with pain, he’s not going to answer ‘Always,’ even if the rest of his stay was okay, or even better than okay.”
Add to this that the survey design leaves no room for elaboration, and it can be hard to know how to improve.
On average, almost 75 percent of Strong Memorial’s survey respondents say they needed medication to control their pain. Almost eight out of 10 patients say that staff always did everything to help with pain, yet only about six out of 10 say their pain was always well controlled. The bottom line: If any patient isn’t satisfied with her pain management here, we’re not satisfied, either.
Committee Takes Action
This is where Strong’s Pain Committee, about a year old, enters the scene.
“To more firmly gasp such a multi-faceted issue, pain management needs to be multi-disciplinary, with those involved ranging from hospital management to patient care techs, from surgeons to pharmacists, from data to nursing pain experts,” Ziegler explained.
The 30-member, cross-disciplinary group has set in place several rigorous efforts to improve pain management. They include:
Zeroing in on patient surveys. For example, our surveys have found the least satisfied demographics in the realm of pain to be 18- to 34-year-old men, and elderly women. The Pain Committee is charged with examining this statistic and responding strategically.
Deputizing about 45 “Nursing Unit Pain Experts.” To build this force, nurse managers on each unit in the entire facility identified nurses who revealed a natural interest in pain management. Onsite experts, they serve as valuable resources both to the unit’s patients and to their colleagues.
Increased patient education. Whether it’s a frank discussion between health care professionals and patients, or a display of posters in patient rooms, we strive to show that we take pain seriously. Recent nurse education has centered on how to talk with patients effectively about pain.
A soon-to-be-implemented algorithm for nurses measuring pain. The Committee gave its final stamp of approval on the algorithm just this April. The algorithm will work as a kind of flow chart for nurses with more nuanced cases, as they tailor appropriate approaches to care. Maybe one patient in pain, in a simplified example, is given Tylenol—his roommate, narcotics. The flowchart helps make sense of different kinds of pain—and the best-recommended treatments.
Auditing various units on their methods of pain documentation, in an attempt to make documentation uniform—the better for comparison as the Committee moves forward.
Managing Pain, Managing Expectations
Managing pain, in large part, starts with setting realistic expectations for what’s possible.
Ziegler noted that, “Patients come into the hospital expecting us to totally free them from pain. Unfortunately, sometimes that’s just not feasible. We will do as much as humanly possible, but that doesn’t always mean there will be absolutely no pain. There are some things we simply can’t control. To partner with them, it’s critical that we’re all on the same page as to what we can achieve.”
In certain cases, that means taking time to distinguish between different types of pain—for example, acute pain, which may resolve quickly, versus longer-lasting chronic pain.
To illustrate just how vital this communication is, Ziegler recalled a scenario in which an elderly patient admitted for surgery at Strong controlled her daytime pain by taking medication every four to six hours. After sleeping through the night, though, she would wake in excruciating pain. This pattern repeated until her nurse asked the patient if she’d like to be awakened to take medication during the night. The staff had been peeking in on the patient at night, see she was sleeping, and leave her undisturbed. No one had ever asked the patient if she wanted to be woken.
But that made all the difference. Once the patient received a dose of medicine during the night, her mornings were much better, and she felt her pain was better controlled.
“All it took was a simple conversation and making a plan with the patient,” Ziegler said.
Jennifer Fortin |
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