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Kaiser Permanente Painscape: Taking Pain Management Beyond the 5th Vital Sign

Primary Author: William Scott Heisler, MBA, RN
Co-Principal Investigators/Collaborators: Christi Zuber
Organization: Kaiser Permanente

Abstract

Background

Approximately 50% of the post-operative patients report having received adequate pain relief during the course of their recovery1*. 1,2,3 The Joint Commission required hospitals to standardize practices around appropriate pain assessment and the management of pain using a scale for measurement (ie 0 – 10 scale).4

Purpose

Managing pain still remains challenging in a clinical setting.3,5,6

Materials & Methods

Better nursing communications needed.7, 8 Better collaboration amongst clinicians, patients and family to manage post-surgical pain.9

Practice Change

Individual Nursing Practice; Focused preparation before room visit; Probe Patient’s Pain, considering functional goals and ADLS; Most appropriate dose for initial transition to PO Pain Medications; Reassess the patient timely.

Team Nursing Practice

Encourage around the clock dosing even if PRN is ordered; Cross-shift support to keep pain regimen going at night.

Evaluation

Improved patient comfort; nurse’s understanding ways to provide pain management; Non-RN Clinical staff evaluation of nursing skill around pain management; Patient informed about pain management.

Results

Decrease in patient’s pain variance2* of 23% on one pilot unit; Nurses showed better understanding of patients needs for pain management (+44%) and improved collaboration with patients (+25%); Non RN Clinicians ratings: Nurse’s Effectiveness (+27); Nurse’ Safer (+13%); Job Easier (+15%); Patients more informed (+19%).

Conclusion

KP Painscape tested on medical units as well.

Lessons Learned

Departments with a pain variance of greater than 1 have more opportunity for improvement. There seems to be a “sweet spot” between .5 and 1 as a range for optimal pain variance

1* Pain variance is the difference between the patient’s stated pain score and their acceptable pain level when a 1 – 10 scale is used. Results cited represent one unit for average pain variance between 5am and 9am.

2* 23 million in a 1992 report and 16.1 million in a 2004 report. Both state 50% or more getting inadequate pain relief.

Bibliography

  1. http://www.ahrq.gov/clinic/medtep/acute.htm#acuteintro
  2. Patient Safety and Quality – An Evidence-Based Handbook for Nurses, Chapter 17.Edited by Ronda G. Hughes. Rockville (MD): Agency for Healthcare Research and Quality (US); April 2008. Publication No.:08-0043. p. 2
  3. McCaffery M. Pain management; problems and Progress. In: McCaffery M, Pasero C. Pain: clinical Manual. 2nd ed. St. Louis, MO: Mosby; 1999. p. 1 – 14
  4. JCAHO. Comprehensive hospital accreditation Manual. Oakbrook Terrace, IL, 2001.
  5. Apfelbaum JL, Chen C, Mehta S, et al. Postoperative pain experience: results from a national survey suggesting postoperative pain continues to be undermanaged. Anesth Analg 203:97:534-40
  6. Hutchinson RW. Challenges in acute post operative pain management. Am J Health Systm Pharm 2007; 64(6 Suppl): S2- S5.
  7. Gittell JH, Fairfield K, Bierbaum B, et al. Impact of Relational coordination on quality of care, postoperative Pain and functioning, and length of stay: A nine-hospital study of surgical patients. Med Care. 2002; 38 (8):807-819.
  8. Horsley J, Crane J, Reynolds MA. Pain: DeliberativeNursing interventions. New York: Grune & Stratton, 1982
  9. Car DR, Jacox AK, Chapman CR, et al. Acute pain Management: Operative or medical procedures and Trauma, No. 1. Rockville, MD: AHCPR pub. No. 920032; Public Health Service; U.S. Dept. of Health and Human Services, 1992.

© Improvement Science Research Network, 2011