TO PROVIDE THE BEST pain management possible for our patients and comply with Joint Commission on Accreditation of Healthcare Organizations (JCAHO) standards, our facility formed an interdisciplinary council to coordinate all aspects of pain management. Here are the areas we focused on and some of the steps we took. We believe our innovations have improved patient care and could be easily adopted by nurses in other facilities. For details on the standards, see What the JCAHO requires.

Involve the patient up front

The basis for an effective pain management program is the recognition that patients have a right to give informed consent and to make decisions involving their care, including decisions about pain management. Include a statement about effective pain management in the hospital's general informational material and in educational tools given to patients and their families. Some topics to cover include:

* information about pain relief measures used by the hospital

* assurance that the staff is knowledgeable about and committed to pain prevention and state-of-the-art pain management and that the staff includes dedicated pain specialists

* assurance that health care professionals will respond quickly to reports of pain and will believe patients' reports of pain.

When talking with your patient about pain management, acknowledge the fears he may have about opioids, especially concerns about addiction and tolerance, and dispel any misconceptions. Our hospital developed an educational pamphlet in English and Spanish that's available on the hospital intranet so staff can print copies for patients. We also established a Health Learning Center that includes books, CDs, and videotapes, many specifically addressing pain-related topics. The center makes computers available to patients and families so they can tap into relevant Internet sites.

Have a comprehensive plan

Based on our experience, we recommend developing a comprehensive policy on pain management to ensure a systematic approach to pain assessment and treatment. The policy should cover all aspects of care, from initial assessment to treatment, reassessment, and discharge planning. It should also provide provisions for ensuring the competency of clinical staff in pain management and patient education.

Our facility's pain council developed versions of the 0-to-10 pain assessment scale in 24 languages and posted them on the hospital's intranet. We also developed laminated pocket cards with the numeric scale on one side and a faces scale on the other side. These were given to every member of the nursing staff, and new staff nurses were taught how to use the scales.

A pain intensity rating of 4 or greater on the 0-to-10 scale was the threshold for intervention established by our council. We consider pain the fifth vital sign and assess and document it with the same frequency as other vital signs.

Our computerized medical record incorporates a standard series of questions about pain on inpatient and outpatient forms, and all vital signs documentation includes pain intensity assessment. The computerized system also can remind nursing staff electronically of the need for intervention and reassessment if the patient's pain rating is 4 or greater.

Every patient's care plan should be individualized and incorporate the patient's goals for effective pain management. With input from many disciplines, our council developed computerized prescriber orders addressing pain. These orders cover patient-controlled analgesia (PCA) pumps, continuous epidural infusions, intravenous (I.V.) infusions, and oral drugs for mild, moderate, and severe pain.

How to put the plan to work

Once you have a policy in place, make sure all staff members follow it to ensure consistent care throughout the patient's hospital stay. The first step in the process is to simply ask the patient if he has pain. Teach nonclinical staff members to help by alerting nurses if they encounter a patient in pain.

Next, assess the patient's pain using a standard pain rating scale appropriate for your patient: Adults may find the 0-to-10 numeric rating scale easy to use, but children respond better to a faces scale. No matter what tool you choose, make sure nurses use the same one on each shift to ensure consistency.

If a patient reports pain, obtain a pain history from him, ask him to rate his pain on the numeric scale, then develop a plan of care to manage the pain. Ask him how the pain has affected his lifestyle and inquire about any religious and cultural beliefs relating to pain. Open-ended questions such as "What does this pain mean to you?" can help you determine if the patient believes pain is a punishment or something that must be endured stoically.

Talk with the patient about his goals for effective pain management. What does he consider an acceptable level or intensity of pain? What are the activities, functions, and quality of life that he hopes to achieve as a result of pain control? For example, he may have a goal of pain at 3 or less, letting him get out of bed and walk after surgery.

In 2004, the JCAHO established patient-safety goals, including a requirement to improve the safety of infusion pumps, particularly those used for PCA and I.V. drug administration. Our council reviewed all our PCA and other pumps to ensure that free-flow delivery couldn't occur.

Evaluate your facility's performance

How well is your pain management plan working? The JCAHO requires facilities to monitor the appropriateness and effectiveness of their pain management plan and seek ways to improve. Talk with your patients about satisfaction with their pain management plan. Consider doing chart audits to determine if the frequency of pain assessment, interventions, and reassessment is appropriate. An electronic health care record can collect this data, letting each unit and department monitor its progress and adherence to policies.

All gain from no pain

The JCAHO's focus on pain management as part of its accreditation process provides an excellent opportunity for improving the way we manage our patients' pain. Use the standards as a guide as you develop strategies to change patient care for the better.

What the JCAHO requires

To meet Joint Commission on Accreditation of Healthcare Organizations (JCAHO) standards, facilities must have policies in place to meet the following requirements.

* Recognize patients' rights to appropriate assessment and management of pain.

* Screen for pain and assess the nature and intensity of pain in all patients.

* Record assessment results in a way that allows regular reassessment and follow-up.

* Determine and ensure that staff is competent in assessing and managing pain. Address pain assessment and management when orienting new clinical staff.

* Establish policies and procedures that support appropriate prescribing of pain medications.

* Ensure that pain doesn't interfere with a patient's participation in rehabilitation.

* Educate patients and their families about effective pain management.

* Address patient needs for symptom management in the discharge planning process.

* Establish a way to collect facility-wide data to monitor the appropriateness and effectiveness of the pain management plan.

Ann Bines is nurse-manager of the brain injury unit at the Rehabilitation Institute of Chicago. Judith A. Paice is director of the cancer pain program in the division of hematology-oncology at Northwestern University's Feinberg School of Medicine in Chicago, Ill.

SELECTED WEB SITES

American Pain Society

http://www.ampainsoc.org

City of Hope Pain and Palliative Care Resource Center

http://www.cityofhope.org/prc

Joint Commission on Accreditation of Healthcare Organizations

http://www.jcaho.org

SELECTED REFERENCES