Spotlight on pain management

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Editor’s note: This feature explores problematic Joint Commission standards with expert advice from BOJ advisors. This month, Elizabeth Di Giacomo-Geffers, RN, MPH, CNAA, BC, CSHA, a healthcare consultant in Trabuco Canyon, CA, and former Joint Commission surveyor, discusses recent changes in the area of pain management.

The Joint Commission (formerly JCAHO) has brought a renewed focus to the area of pain management with its recently released brochure, “What You Should Know About Pain Management,” as part of the accrediting body’s Speak Up program.

Pain management has been on The Joint Commission’s radar for quite some time. Since 2000, it has been a part of The Joint Commission’s national standards as well as the accreditation process.

Pain is one of the major reasons patients seek care. However, hospitals continue to struggle with the issue. According to Joint Commission officials at the 2009 Executive Briefings, pain assessment and reassessment is a top 10 most-cited standard under PC.8.10 (soon to be PC.01.02.07), for which hospitals received RFIs in 16% of surveys in 2007 and the first quarter of this year.

The brochure provides some excellent advice for pain management but has a few holes your facility should watch for:

Be aware of your patients’ cultural needs. The Joint Commission brochure is available in Spanish, but be prepared to communicate about pain in the languages and dialects common to your area.

Literacy is important here: Does your facility have written materials you can provide to patients in their native language to help them understand and assess their pain needs?

Pain is population specific, varying with factors such as age, cultural diversity, and cognitive impairments. It takes a delicate understanding to sense, using verbal and nonverbal communication, the level of pain a patient is experiencing, especially when he or she is ventilated or cognitively impaired, such as a patient with Alzheimer’s.

Pain is in the eye of the beholder. As pain management pioneer Margo McCafferey wrote in 1968, “Pain is what the patient says it is, and it’s as bad as the patient says.”

Know how to educate those who are caring for a population that cannot communicate its pain. The Joint Commission brochure focuses on adult pain management quite well but does not specifically address the pediatric population. With pediatric medication errors so high, it will benefit your facility to take the time to understand the pain management and pain assessment needs for children, particularly those too young to explain their own pain.

The real key here is knowledge. We must educate everyone involved with the patient. Nurses, physicians, respiratory therapists, physical therapists, dietitians, residents, and even counselors should receive education on how to assess and manage pain in their patients. Most healthcare providers do well when it is expected that the patient will experience pain (e.g., after surgery). However, without cues such as an incision site, providers may forget to ask about pain.

It boils down to assessment and reassessment. If you don’t educate people on pain pathophysiology, they will not be able to get their arms around this issue.

Policy. Take a look at your policy. When it comes to pain management, an RFI can be a self-inflicted wound. Is your pain assessment and management policy too tight? Does it need to be clarified or simplified? Did staff members have input into its design?

Like any policy, a pain assessment policy that is too stringent can leave your organization open to an RFI simply because it is impossible for staff members to reasonably comply with it.

Speak with frontline staff members. Listen to how they assess pain and the steps they go through to determine the level of pain in their patients and craft an effective policy from that information.

Documentation. A successful pain management policy can be derailed by a lack of documentation. Many facilities assess pain but fail to document it in accordance with their policies.

Examine your policies: Can your staff comply with the policies as written? Does the practice follow the policies? If not, why not?

If you find that people are not documenting their assessments or reassessments, ask why. Is it a knowledge deficit? Is it a process problem? Are you requiring documentation in multiple places? Is the documentation too detailed, taking up too much time, or interfering with other patient needs?

Drill down to the root cause of the problem. This may vary from organization to organization. The number of RFIs has increased 1% this year—why is it still so high when we know most caregivers are doing an excellent job? What we know is, very often, caregivers are not capturing their excellence in writing or they are documenting it but not in accordance with existing policies.

We need to find out why caregivers are not capturing their practices in writing. Is it a practitioner issue or is it a global issue?

Look at the system, the technology involved, and the policy for where holes might exist.

Other standards. Where should hospitals focus to make sure they are meeting patient needs in pain assessment and management?

Let’s start with the basics. RI.2.160 (in 2009 identified as standard RI.01.01.01, element of performance [EP] 8, an A EP) states that patients have the right to pain management.

Education for patients and their families is key. Also, look at what your facility is using to assess pain. There are many pain rating scale tools available on the Web (one excellent resource is UCLA’s pain management center at Are your tools simple to use?

Remember, it’s not just nursing that needs to use this scale. MS.03.01.03, EP 2 (an A EP), requires hospitals to educate all licensed independent practitioners about pain management and assessment. This is new for 2009.

HR.01.04.01, EP 4 (a C EP, requiring a measure of success and documentation, designated in the manual with M and D), also addresses staff education, requiring hospitals to orient staff members on assessment and management of pain.

PC.03.01.07, EP 2 (a C EP, requiring a measure of success and a direct effect requirement), looks at operative or high-risk procedures and monitoring pain. For this EP, you should track the frequency and intensity of pain as it relates to the potential effect of the operative or high-risk procedure.

PC.8.10/PC.01.02.07 (all EPs) similarly requires hospitals to assess pain consistently with regard to the patient’s age and cognitive ability.

Information provided to the patient should include discussion of the patient’s pain, activities that increase the pain, and the importance for the patient to effectively manage his or her pain.

Many practitioners fear providing pain medicine because of the possibility of addiction. However, many med-ications are not as effective if they are not administered early when the onset of pain begins, as opposed to later when the pain reaches its apex.

Properly addressing pain assessment and management boils down to education on all sides. Facilities need to target and increase knowledge in caregivers. Training caregivers about the value of adequate pain management should begin in medical and nursing school.