Take the Pain Out of Pain Reassessments in Three Steps
Accreditation Monthly, October 7, 2008
Most hospitals have an 80% intrinsic rate of compliance with their pain reassessment policy. This is usually good enough to meet 2008 expectations, but it will not be nearly good enough for 2009 (90% will be the minimum level of performance). The challenge is that the bedside nurse has no reason to go back to the chart when he or she determines that a pain medication has been effective. If another dose is needed, no problem: The nurse is in the chart for the follow-up dose of medications anyway. If another dose is not needed, however, the nurse is not inclined to revisit the chart just to document that all is well—it just isn't natural.
Step 1: Separate pain management from pain assessment. Take your requirements for assessment and reassessment of pain out of your pain management policy. In fact, make your pain management policy one sentence: "Patients in this organization shall have the right to effective pain management" (RI.01.01.01, EP.8). The rest of the material on effective pain management should be in the form of educational material for clinical personnel. Effective pain management is a journey, not a destination, so educate, educate, educate. But don't require specific pain management steps: patients are individuals, and managing their pain will be individualized accordingly.
Step 2: Simplify pain assessment requirements. The Joint Commission requires that there be a policy for patients who may need a more in depth assessment of pain (PC.01.02.01, EP.2); there be a comprehensive initial pain assessment that is consistent with the organization's scope of care, treatment, and services and the patient's condition. (PC.01.02.07, EP.1); clinical personnel reassess and respond to the patient's pain according to reassessment criteria (PC.01.02.07, EP.3); and age- and condition- appropriate assessment methods be used (PC.01.02.07, EP.2).
Consider the following:
- If you have a trigger for a more in-depth assessment, put it in a generic initial assessment and screening policy; keep it out of your pain policy. (Reflect what's already happening, don't make up something new.)
- Mention the pain scales to be used in the policy, but keep the details of the various scales out of your policy. Leave the details to your education documents.
- Do not specify a scale for nonverbal adults. No reliable scale exists (remember, FLACC is for infants, not adults).
- Allow documentation of "patient sleeping," "resting comfortably," and similar observations in lieu of a pain scale at the time of the post intervention reassessment.
- Make the details of the comprehensive initial assessment vague. Leave it to "location, intensity, and nature." Put the details in the forms for the various settings (emergency departments can therefore be appropriately different from inpatient and procedural areas).
- Only require pain assessments in the general ambulatory setting for patients complaining of pain and allow the provider's note to suffice for the pain assessment.
- Remember our general rule: No policy should be over 1.5 pages in length.
Step 3: Allow end-of-shift documentation. Although the policy should specify that the reassessment should take place within a clinically appropriate time frame (e.g., within a half hour of intravenous doses or within an hour of an oral dose), the documentation of this reassessment may be deferred until the end of the shift. This then allows a number of options for documentation (which is the subject for our other Stop the Madness articles and approaches for easing nursing's documentation burden).
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