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The patients at Good Samaritan Hospital in Baltimore had a problem: No one was asking about their pain. When they filled out their patient satisfaction surveys, they let administration know that this was an area where they were less than satisfied with their care. So two years ago, the hospital acted, hiring Deborah O’Loane, RN, MSN, as pain management coordinator to develop a program from scratch. Her first job was simply to get people to ask patients about pain. "I remember one doctor insisting his patients weren’t in pain. So I said to him, Have you asked them? Because they tell me they are in pain.’"
Part of the problem stems from early 20th century laws that "put the scare" on physicians, says O’Loane. A lot of people continue to have misconceptions about the likelihood of addiction to needed pain medications, she says, when the reality is that only about 1% of patients will develop problems. Those attitudes are slowly changing. With new guidelines and the emphasis that the Joint Commission on Accreditation of Healthcare Organizations is putting on pain management, some physicians are starting to change their tune.
O’Loane assembled a multidisciplinary team of nurses, physicians, pharmacists, physical therapists, and medical ethicists to put together appropriate policies and procedures and to spread the word about pain management. The cornerstone of successful pain management is assessing the patients, she says, and the hospital has developed several scales to do so — including numerical scales, with 0 equaling no pain to 10 meaning the worst pain possible; a faces scale, with six different faces ranging from happy to tearful; and word scales. O’Loane also advises making sure patients and physicians use the same words to describe pain.
Another key element is to make sure patients are educated about pain, too, O’Loane explains. Along with an extensive Web page on their site devoted to pain (www.goodsam-md.org/news/pain.cfm), patients are encouraged to attend preoperative educational classes. "Part of that is about pain management, what they can expect, and telling them to let us know about their pain," she says. Preadmission packages also include a two-page document about pain that has some of the pain assessment tools on it, along with information on pain management and the importance of the patient’s role in it.
At the East Orange (NJ) VA Hospital, asking is built into the program. There, as with the entire VA system, pain assessment is a "fifth vital sign," says Victor Chang, MD, staff physician and director of palliative care at the hospital. "We know pain is underassessed. This is a way for us to do it without having to think about it."
Health care professionals often are more interested in diagnosis and treatment, he continues, and pain can be put on the sidelines. In addition, patients sometimes look comfortable and are themselves focusing on medical issues, says Shirley Hwang, RN, MS, oncology clinical nurse specialist and coordinator of palliative care program for the oncology and hematology unit at the 300-bed hospital. "They may figure that they have had pain for a while and can tolerate it, so they don’t report it," she says. "Or they view it as an issue of age."
Patients are assessed for pain at least once per shift, she explains, giving nurses a number on a 0 to 10 scale to describe their pain. If they have pain and are given palliative treatment, then there is additional assessment to determine its efficacy.
Two years into the program, it hasn’t been a problem to create the habit of asking about pain, says Chang. "But then you have to understand the meaning behind the number. For physicians it can be hard because one person’s 4 is another person’s 8. "It’s not an objective value like a temperature. But we are finding that there is a reliable correlation between the number they give and function and mood," he says. "We still have to educate physicians more about that."
And there has to be training about when immediate action is needed. "If someone says they have pain that is a 10, then it’s a 10," Chang says. "You wouldn’t send someone home if they were short of breath. This might not be a fatal illness, but it should have a very high priority."
Hwang says anything higher than 8 should be dealt with immediately.
"The real lesson is you can’t bang it over their head," O’Loane says. "You have to provide education and let them see the effectiveness over time. People have basic beliefs and misconceptions regarding pain. But after a year or so, they start to see results. Patients are happier; there are fewer side effects." And along with that, there are improvements in length of stay that O’Loane says are directly related to better pain management. "If you don’t manage pain, you have increased risk of pneumonia because people can’t move or cough effectively. There is increased risk of pressure ulcers and blood clots. And pain decreases the effectiveness of the immune system, so people heal more slowly."
At Good Samaritan, an example of the improvements is with patients who come in for total joint replacement. Length of stay has declined from three days to about 2.5 days, she says. The VA still is assessing the value of its program. Chang says administrators know that patients are being asked about pain more frequently, and in Hwang’s unit, patients with severe cancer pain are getting treatment for that pain. Further study is needed, however.
O’Loane says the best advice she has for others intent on revamping their pain management programs is to put someone in charge who knows pain management. "Knowledge about this area is vital," she says. "And be patient; you can’t effect change overnight."
[For more information, contact:
• Deborah O’Loane, RN, MSN, Pain Management Coordinator, Good Samaritan Hospital, 5601 Loch Raven Blvd., Baltimore, MD 21239. Telephone: (410) 532-4296.
• Victor Chang, MD, Staff Physician, Director of Palliative Care, East Orange VA Hospital, VA New Jersey Health Care System, Section of Hematology/ Oncology, 385 Tremont Ave., East Orange, NJ 07018. Telephone: (973) 676-1000.
• Shirley Hwang, RN, MS, Oncology Clinical Nurse Specialist, Coordinator, Palliative Care Program, East Orange VA Hospital. Telephone: (973) 676-1000.]