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Hospice, home care benefit from training
When the opportunity arose to learn the latest pain management assessment techniques and treatment guidelines, Lutheran Home Care Agency & Hospice of Hope in Frankenmuth, MI, took full advantage.
The freestanding, nonprofit agency that serves a 50-mile radius in the rural, thumb-area of Michigan volunteered to be part of the Michigan Cancer Pain Initiative and committed staff and time to improving pain assessment and management training and education.
Developing QI projects
Joining the pain initiative project was a natural fit since the agency has begun to make pain management a top priority, partly because of documentation requirements on the Outcome and Assessment Information Set (OASIS) form, says Donna Zwerk, RN, BA, director of the certified and private division.
The agency also is one of the pilot programs for the Michigan Peer Review Organizations (MPRO) and has chosen pain assessment and management as part of its Outcome-Based Quality Improvement (OBQI) project.
All of these quality improvement (QI) type of projects and efforts will help the agency improve outcomes under the prospective payment system (PPS), Zwerk says.
"One of the positive things with PPS is the nurse now is the case manager, and she can see the patient. If she needs to come back the next day or next three days in a row to help the patient get a good handle on pain and medications, she can do this because the agency is paid in one lump sum," Zwerk notes.
Patients now have more acute problems
"We’re seeing patients with such acute problems that if we’d seen them 10 years ago, someone would have been taking care of them on the surgical floor," Zwerk adds. "So there are a lot more ill patients, and they have a lot more pain needs than what we were used to seeing in home care, and that has to be addressed right up front."
Often these acutely ill patients had been receiving medication through a pain pump in the hospital, but are switched to oral medications when they are sent home. This means that home care nurses might encounter instances in which the patients’ pain is not working adequately, she explains.
Also, patients may need to be seen by therapists and other disciplines, but if their pain isn’t adequately managed, then patients will not be able to tolerate therapy.
All of these issues mean that today’s home health nurse needs to know a great deal more about pain assessment and management than was required in the past.
As part of this educational process, Lutheran Home Care staff attended conferences that highlighted pain management best practices and benchmarks, says Lynn Zuellig, RN, BSN, hospice director.
"It was a fantastic collection of professionals and experts in the field who could talk to what was the standard of practice," Zuellig says. "There was a lot of networking going on, so people in small agencies could connect with people in other small agencies."
The Michigan Cancer Pain Initiative led the pain management quality improvement project in the state and provided training materials in conjunction with the American Alliance of Cancer Pain Initiatives in Madison, WI. The project’s main conference combined lecture format and interactive workshops at which specific materials from the Wisconsin organization were presented, says Penny Murphy, MS, RNC, CRNH, project director of the Michigan Cancer Pain Initiative in Fenton, MI.
Each agency, including Lutheran Home Care, sent three people to attend the conference, and they were taught everything from assessing pain to regulation issues. (See story on what the pain project entails, p. 103.)
From a quality improvement perspective, smaller agencies can save money and improve training techniques by using strategies taught by organizations, such as the American Alliance of Cancer Pain Initiative, Zuellig says.
"We didn’t have to start from scratch," Zuellig explains. "We were using a manual on building an institutional commitment to pain management, and in there are quality improvement tools, reporting tools, policies and procedures, and mission statements addressing pain."
Videos, QI tools available for training
The pain project also has provided participating agencies with access to educational video tapes, standards of practice, nursing competencies, flow sheets, critical pathways specific for pain, pocket and reference cards, posters, and case conference and case study guides, Zuellig adds. (See resource guide for more information on pain management tools, p. 104.)
Staff training about pain management began shortly after Zuellig and colleagues attended the pain conference.
"We started with nursing meetings at the first
of March, telling them about the program on pain management," says Donna Zwerk, RN, BA, director of the certified and private division of Lutheran Home Care Agency & Hospice of Hope.
Along with staff education, Zwerk and Zuellig initiated a chart audit process in which Zwerk and two clinical supervisors looked at 17 admission charts for the following indicators:
• Does the patient have pain?
• Is the patient on any pain medications?
• Does the patient have intractable pain?
• Is pain addressed on the follow-up plan of care?
• Was the pain scale used?
"We kept the audit very basic and reviewed the same charts again at 10 days to two weeks after admission," Zuellig says. "At the follow-up, we asked, Was the pain scale used on every visit, and was the pain level addressed?’"
Identifying and fixing problems
After auditing 17 charts, they discovered that 15 patients had pain at admission, but only seven had pain that was addressed on the nursing plan of care. Also, the pain scale was not consistently used, and the onset frequency and origin and duration often were not completed, Zuellig says.
Zuellig and other supervisors reached the conclusion that while it was possible the audit missed some things, the agency probably wasn’t doing as good a job as they needed to do.
So they began to renew educational efforts, including having home health nurses do
chart audits so they could see the problems
"We ask nurses, What do you see that could be done differently?’ and it’s amazing what they see in their own charts," Zwerk says. "One nurse said, This is my chart, and I don’t want to tattle on myself, but maybe I could do this differently.’"
Supervisors also asked nurses to assess the agency’s OASIS tool for problems with how pain is assessed.
"We had nurses look at our current OASIS pain assessment tool and rate it according to what they heard on the educational videotape about what the tool’s strengths and weaknesses were," Zuellig says.
Nurses have pocket pain guides
One drawback to their tool was that it couldn’t be easily adjusted by adding a question or two because of the way it had been designed by the OASIS tool contractor. This led the staff to consider making a small pocket reference tool that nurses could carry with them while assessing patients for pain. The pocket guide would give them cues on assessment and documentation of pain.
"We gave them pain sticks to keep in their pocket, and these have a visual analog for rating pain from zero to 10," Zuellig says. "One side is a color chart and numeric scale, and the other has a face scale with happy faces."
The staff concluded that the OASIS tool adequately assessed pain intensity, quality, location, duration, origination, whether it varied from day-to-day, what makes it worse, impact on sleep and quality of life, analgesic history, barriers to reporting pain, and physical findings at the site of pain.
However, the supervisors disagreed. While the tool asked all of those questions, it did so in a large paragraph instead of asking each question individually, Zuellig explains.
For example, one question on the OASIS tool reads, "Is the patient experiencing pain that is not easily relieved, occurs at least daily, and affects the patient’s sleep, appetite, physical or emotional activity, concentration, personal relationships, emotions or ability or desire to perform physical activity?"
Nurses then have to answer "yes" or "no" to the question, even when some of the points might be true while others are not, Zuellig says.
"We felt that was not adequate because there was too much lumped in there, and you can’t pull it out on the tool," she says. "But on the pocket guide, it will pull all of these questions out."
Revamping the pain scale
Another problem was that the OASIS used a pain scale of one to 10, which Zuellig and other managers did not feel was adequate. "We wanted the scale to be from zero to 10," Zuellig says.
"We can get a more accurate assessment that is more in line with what people are using nationally by making it from zero to 10," she adds.
Chart audits also revealed the agency’s need
to train nurses how to provide better follow-through on the nursing care plan, Zuellig says.
"They need to be able to distinguish those patients who had pain on admission and a need for follow-up on subsequent nursing visits," Zuellig adds. "Another goal is for the pain scale to be used on each visit and not just on every other visit or visits by the primary nurse."
As part of the pain project, the agency will make all practical and necessary changes in documentation, assessment, and treatment, and then monitor patients for improvements in pain management.
It’s too early in the project for results, but the staff’s response to education has been encouraging, Zwerk says. "I expect our outcomes will improve."