What You Need to Know
BWH’s next site survey from the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) is slated for January 2004. To help prepare nurses for the impending survey, BWH Nurse will continue to publish regular articles on appropriate processes and standards that apply to Nursing.
All nurses, who have not yet been through a JCAHO Survey, should work with their nurse managers and clinical educators to ensure understanding and expectations of the process.
Part IV. Pain Management
Pain is the most common reason patients seek medical attention. There are numerous articles in the literature that suggest that pain is undertreated despite the availability of pharmacological and non-pharmacological therapies.
JCAHO recognizes pain as a major, yet avoidable, problem. For this reason, it has established regulatory standards, which have been endorsed by the American Pain Society (APS). JCAHO has incorporated a pain focus in six of its standards:
1) Rights and Ethics – Every patient has the right to appropriate assessment and management of pain. This standard represents an organizational commitment to pain management. BWH’s commitment to this standard is reflected in its Patient’s Bill of Rights, which are posted on all nursing units. The hospital also has defined Administrative Guidelines for Analgesia and Sedation (available on-line in BICS Administrative Guidelines), which outline minimum criteria for all policies and procedures related to the safe and effective pain management of patients.
2) Assessment of Patients – Every patient should be assessed for the presence and (if so), the nature and intensity of pain. The In-Patient Patient Assessment Form incorporates all the critical
elements that must be addressed for all patients who acknowledge existence of pain. This includes the use of an intensity scale to describe severity, location, duration and measures used to control pain. Ambulatory Services is currently developing an assessment form to facilitate pain assessment of patients in medical-surgical and specialty services. Results of medical record reviews for the month of March show that only 62 percent of the patients were assessed for the presence of pain on admission. This is an area that demands our focused attention as we strive to achieve a minimum target of 90 percent compliance.
3) Care of Patients – Policies and procedures must be developed and implemented that support the appropriate prescribing of effective pain medication. This standard states that one of the goals of treating patients is addressing pain that may be associated with their disease, condition or treatment. BWH has established policies and procedures for the administration of analgesics via PCA, Epidural or Intrathecal modalities. Clinical pathways recently developed and/or revised assessment and management of pain for each day of the patient’s hospital stay. BWH recognizes pain as “the fifth vital sign,” and that the patient’s report of pain is the single best indicator (behavioral indicators may be used if the patient is unable to self-report). If pain is determined to be present, consideration should be given to assessing and documenting pain with other vital signs. Pain should also be assessed before and after all known pain-producing events (i.e. interventional procedures, treatments, etc.).
4) Education of Patients – Patients and their families must be educated about pain management. This standard states that health care organizations have a responsibility for helping patients understand the importance of pain management as a part of their treatment. This includes presenting accurate information on pain medication and
dispelling myths. For patients who are receiving pain analgesia via PCA, epidural or intrathecal infusions, we need to make sure that they understand symptoms that need to be reported, in addition to rating the intensity of their pain in response to the pain medications.
5. Continuum of Care – Patients’ needs for symptom management should be addressed in the discharge planning process. We have a responsibility for helping patients and families adapt to the plan of care, which may include post-discharge pain management instructions and follow-up. Results of medical record reviews for the month of March show that 98 percent of patients received instruction on pain management.
6. Improving Organization Performance – Pain management must be incorporated into an organization’s performance measurement and improvement program. This standard states that healthcare providers should collect data to monitor the appropriateness and effectiveness
of pain management. Patient satisfaction surveys conducted by the hospital include questions on pain management. As mentioned above, medical records are reviewed by nurse managers on a monthly basis, to measure compliance with JCAHO standards on pain management.