Better pain management = fewer pressure ulcers: revising the pain-assessment protocol in this rehab unit lowered the number of facility-acquired pressure ulcers by 69%. (Feature Article).

When the Delmarva Foundation for Medical Care, Maryland's Quality Improvement Organization (QIO) under the Centers for Medicare and Medicaid Services (CMS) nursing home quality initiative (NHQI),met with its select group of nursing homes in the pilot state to brainstorm, the director of nursing and administrative team from St. Mary's Nursing Center in Leonardtown, Maryland, came up with a novel approach to pressure-ulcer prevention: pain management.

A quality-assurance study at St. Mary's. which has 170 long-term care beds and 42 rehab beds, had shown that one-third of all facility-acquired wounds were developing in the rehab unit. Therefore, the administrative team--consisting of Director of Nursing Monica Hayden, Assistant Director of Nursing Missey O'Brien, Quality Assurance Coordinator Debi Achtellik, and Administrator Donald Lewis--proposed that improved pain management in that unit might lead to a better pressure-ulcer report card, since people experiencing pain tend to be less mobile than those without pain or whose pain is controlled. They were correct.

Beginning in July 2002, a revised protocol for pain management was instituted at the facility. Under the new protocol, pain was assessed upon admission and the third day after admission. If the follow-up assessment revealed the presence of daily pain, the attending physician was contacted to obtain a pain medication. Follow-up pain and skin assessments were to continue through four weeks postadmission, or until the pain was resolved. Before the initiation of the newprotocol, residents' pain was assessed only upon admission.

The revised protocol was refined further once the program got under way, when it was determined that staff follow-through was still lacking after the second pain assessment. To correct this problem, the protocol was changed: It now includes pain assessments every three days until pain control is achieved, then weekly for four weeks, then monthly thereafter.

The pain assessment form used at St. Mary's was also revised. The new form is designed to detect more than one source or type of pain, focusing on quality, rather than intensity, of pain. Hayden explains, "The main issue is how many sources of pain are there? Then we need to determine what its qualities are. Is it a burning pain? Is it pressure? Where is it?"

The form asks whether the resident has pain now, has had pain in the last 7 days, and has pain in more than one location. Also included on the form are line drawings (body charts), on which residents (or their family members! friends/other representatives) can mark the location of each pain. Then residents are asked to "describe each pain in the resident's own words (i.e., burning, stinging, stabbing, deep ache, numbness, cramp, tightening, worse on movement or breathing, etc.)," and to designate whether the pain is "constant" or "intermittent." Further questions are included regarding each pain marked on the body charts, to determine whether this pain occurs daily, at what time of day, and what makes it better or worse.

"The answers to these questions give the physician a great deal of useful information to help him direct treatment," says Hayden.

By the end of this program in September 2002, the incidence of facility acquired pressure ulcers in the rehab unit had dropped by 69%, according to Hayden. She says, "Benefits we hadn't specifically anticipated included fewer complaints from residents, fewer dressing changes, and fewer nurse-call bells to answer. The residents are up and more mobile than before, and both staff and residents are happier. Our quality-assurance coordinator is tracking the outcomes data, but these improvements certainly attest to the program's success.

Hayden says the pressure-ulcer prevention program was successful, in large part, because of St. Mary's Nursing Center's supportive medical director, who even opted to attend the Delmarva meetings with her, and a proactive nurse practitioner, who helped a great deal with pain control. Hayden also emphasizes the benefits of being in an NHQI pilot state and working with a QIO: "Meeting with Delmarva gave us an outlet where we could brainstorm, and they've been very supportive. They wanted us to take one small measure of change and see its impact. Although this turned out to be a larger project than we had anticipated, it's been so successful."

Now the task at hand is to expand the program. Hayden says that St. Mary's is now in the process of instituting the pain-management protocol throughout the facility, initiating it in one additional unit at a time.

Monica Hayden, RN, CRRN, is director of nursing at St. Mary's Nursing Center, Leonardtown, Maryland. For more information, e-mail [e-mail]. For more information on the Delmarva Foundation for Medical Care, phone [phone]; fax [phone]; e-mail [e-mail]; or visit www.dfmc.org. To comment on this article, please send email to [e-mail].