Facility cuts timelines, develops a standardized pain tool

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Best practice

There are various ways pain can be measured by hospital staff members, depending on the organization. At Altru Health System (AHS) in Grand Forks, ND, patients receive a comprehensive pain assessment upon admission and a pain assessment during every shift thereafter.

To ensure that the pain assessment and reassessment were being documented, AHS conducted monthly chart audits.

The data collected from these monthly chart audits for the Joint Commission Provision of Care standards revealed low compliance with timely documentation of pain reassessment.

The Pain Management Committee at AHS began revisions of the pain assessment policy after recommendations for policy revisions from Patricia Pejakovich, RN, BSN, MPA, CPHQ, CSHA, senior consultant at The Greeley Company, a division of HCPro, Inc., in Marblehead, MA, and Janelle Holth, RN BSN, AHS’ regulatory compliance coordinator.


Reassessment for time and policy

Chart audit data indicated that the reassessment for inpatients was not being documented within the timelines written in the pain assessment policy.

“For example, if a nurse gave a patient medication through an IV, which is supposed to be reassessed within a half hour, it was not happening within that time frame,” says Holth.

AHS has electronic medical records, so even though nurses were able to reassess and document patients’ pain before the end of their shift, the reassessments were not making it into the records within the required time because of the distance to the computers.

The computers are located in the hallways rather than the bedside, which adds steps to the work flow process.

After discussing and clarifying the requirements, AHS removed timeliness for reassessment from its policy. This allowed the nursing staff to focus on pain management without interrupting patient care.

Nursing staff members were also able to reference the time pain was reassessed within their documentation before the end of their shift.

Beneficial options for nursing staff

In addition to removing timelines from the pain reassessment process, AHS added other options for where nurses could document each reassessment they completed. There are three options available for nurses to choose from when they document pain reassessment.

The first is a medication tab located under the comments section in the electronic record. The second is displayed in the nurses’ notes under the shift-to-shift summary note in the electronic record.

The third option is more commonly used on the oncology floor. A flow sheet is used by nurses so all medications and times can be viewed immediately.

“The most common method used for pain reassessment is the comments section within the medication tab located in the electronic record,” says Holth.

Health system standardization

Once the revision of the pain assessment policy was complete, Nancy Joyner, clinical nurse specialist and cochair of the pain management committee at AHS, began working on a tool for pain assessment that would be standardized and consistent throughout the facility.

One thing that stood out to Joyner was the absence of a nonverbal pain scale.

“With only a verbal pain scale available, nurses did not have a tool to use for the cognitively impaired patient,” says Jodi Savat, RN, BSN, OCN, patient care supervisor at AHS.

When dealing with patients who were unable to express how much pain they felt, many nurses took an educated guess by using visual cues.

Through research and with help from Pejakovich, Joyner developed a comprehensive pain assessment tool.

Joyner reviewed and researched nonverbal behavioral tools and elicited the assistance of the American Society of Pain Management Nursing’s listserv.

Joyner, Holth, and Pejakovich decided that nonverbal pain scales using behavioral and physical signs were most appropriate for AHS.

The tool that seemed best fit for AHS for adults was the Nonverbal Behavioral Pain Scale for Cognitively Impaired Patients. This scale uses a nursing report, not a self-report, and is reflected as such in the nursing notes.

Based on a 1–10 scale, which is broken down into sections, pain descriptions are listed under each section to help nurses determine the patient’s level of pain.

A score of 1–3 in the first section indicates the least amount of pain. The scale proceeds to 4–6 and 7–9, with 10 being the most pain a patient can be in. Under each section are cues to help nurses determine what degree of pain the patient is in.

“The nurse looks at the behaviors and vital sign cues and correlates them with a number on the nonverbal scale,” says Savat.

“At first, it was difficult to decide if the visual and vital sign cues were due to pain or something physiological going on,” says Doreen Lindsey, RN, BSN, supervisor of patient care in the intensive care unit/critical care unit (ICU/CCU) at AHS. “But with continued education and continued use of the nonverbal scale, nurses became more accustomed to looking at the whole picture of the patient status.”

The tool also incorporates the Neonatal/Infant Pain Scale; the Neonatal, Pain, Agitation, and Sedation Scale; the Faces, Leg, Activity, Cry, Consolability (FLACC) Scale; and the FACES Scale (see the tool on p. 6). All the pain assessments are included in a single poster that AHS has placed throughout the health system. This makes it easy for staff nurses in any department to assess patients regardless of their age or mental state.

“We received great reviews pertaining to this tool because it was standardized, consistent, and beneficial to all staff members in the health system,” says Holth.

The new system will allow the pain reassessment documentation to be linked to documentation of a medication that has been administered.

“The important thing is that this is ongoing and that pain reassessment is not a guessing game,” says Holth.

“It takes a lot of education to change the culture,” says Savat.