Pain: The Fifth Vital Sign
Crozer-Keystone VHA RAN Project Aims to Improve Patient Satisfaction with Pain Management
Pain affects 76.2 million Americans, more than one-quarter of the U.S. adult population, according to the National Center for Health Statistics (NCHS). Research has shown that pain can weaken the immune system, slow recovery from disease or injury and negatively affect the emotional well being of patients and their caregivers. The American Pain Society and other healthcare organizations consider pain control so essential to a patient’s well being that they have designated pain as the “the fifth vital sign.” Although evidence shows that good pain control results in fewer complications, faster healing and decreased hospital stays, pain continues to be untreated, undertreated or improperly managed nationwide, according to the NCHS report (2006).
Improving patient satisfaction with pain management is a primary goal of the Crozer-Keystone Health System. In 2009, a team from Delaware County Memorial Hospital began work on a VHA Rapid Adoption Network (RAN) project focused on improving Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) scores related to two pain questions:
- During this hospital stay, how often was your pain well controlled?
- During this hospital stay, how often did the hospital staff do everything they could to help you with your pain?
CKHS typically scores well on the first question, but hasn’t fared as well on the second. Crozer-Keystone has established performance improvement goals for pain. According to the CKHS Pain Committee, the keys to reaching these goals include improved communication between nurse and patient, better documentation of pain, and better tools for pain assessment and management.
The DCMH VHA RAN team began tackling the challenge at a VHA Clinical Design Day held in October 2009. Led by Susan Foster, RN, BSN, MHA, clinical director of Orthopedics and Surgical Services, 5 East, the team includes Mary Moser Grimes, RN, and John Hornyak, RPh. Together, they outlined current pain management processes at DCMH, learned skills for observing and identifying opportunities for improvement, and discussed best practices that have enabled VHA hospitals to dramatically improve their HCAHPS scores.
Subsequently, Foster worked with the DCMH 5 East Unit Council to develop patient-focused pain management initiatives and implement a pilot program on the unit.
The pilot includes:
- Ensuring that pain is addressed during hourly rounding.
- Posting a numeric goal for pain management on the white board in each patient room, along with the time when the patient’s next dose of pain medication is due. “It’s important to set realistic goals,” notes Foster. “If the patient says their pain is a 10, it will probably be unrealistic to think we can get them to 0. If we write down a more realistic goal of 2 and let them know when they can have more pain meds, they are more likely to successfully ride out the pain and feel satisfied with the way it was managed.”
- Opening medication in front of the patient and explaining each one to the patient. “In addition to improving patient satisfaction with pain management, this best practice also facilitates patient education and medication reconciliation,” says Foster.
- Providing patient education. The 5 East Unit Council developed a poster to help patients better understand and more accurately rate their pain on a numeric scale.
Foster also plans to conduct manager rounding with all patients on 5 East to tell them that they should expect hourly rounding for pain management. “Accountability is key at every level, and manager rounding sets the stage for us to be accountable to the patient regarding their pain management. In addition to ensuring that our patients receive the best care, we are also ensuring the economic health of our system. Ultimately, our Medicare reimbursement depends on our HCAHPS scores.”
Implementing Best Practices
If the pilot on 5 East is successful, the VHA RAN team will recommend that these or similar practices be implemented throughout DCMH and ultimately, at all CKHS hospitals. In preparation, the team has begun training sessions for all DCMH clinical directors, who will then bring the training back to their units.
“The specific practices that work on 5 East might not necessarily work for others,” Foster advises. “Each unit may need to develop their own to meet the needs of their specific patient population. However, one message that we are conveying is the same for everyone: Clear communication about pain management between patient and nurse is essential. The nursing staff needs to communicate unequivocally to the patient that pain relief is essential to their recovery and that we will do everything we possibly can to manage their pain effectively. We must be clear about expectations and be sure that both patient and nurse are on the same page.
“Effective pain management goes far beyond the tasks of hourly rounding and administering medications,” Foster adds. “We must convey to our patients that we are focused on them as individuals and committed to ensuring that they receive the best possible pain relief while they are in our care.”
DCMH VHA Rapid Adoption Network Team - Pain
Susan Foster, RN, BSN, MHA, Team Leader
Mary Moser Grimes, RN
John Hornyak, RPh
CKHS Pain Committee
Alisha Hartunian, RN, BSN, Taylor, Leader
Christina Clay, M.D., Crozer/Taylor
Dolly Curley, RN, BSN, BS, DABFN, LNCC, CKHS Home Care
John Davidyock, M.D., Crozer
Susan Foster, RN, BSN, MHA, DCMH
Rob Fox, MSN, Crozer
Debbie Gifford, RN, BSN, Taylor
Sue Griffin, RN, Taylor
Maureen Ingram, RNC, MSN, CWOCN, DCMH
Beth Ann McClure, RN, Crozer
Richard Pacitti, PharmD, Crozer
Christina Reinhardt, RN, Crozer
Terry Sandman, RN-BC, CHPN, Crozer
Note: VHA RAN projects currently underway at Crozer-Chester Medical Center and Taylor Hospital will be featured in future issues.