Pain management lessons from the field.

As many as 80 percent of nursing home residents live with chronic pain, much of it unrecognized and untreated. Despite increased focus on pain identification and treatment the past few years, many care facilities still struggle to establish pain management programs. We asked some nursing administrators who have implemented programs to share their strategies.

Getting started

When Greg Wainman, was nurse manager at Birchwood Health Care Center in Lake, Minn., he was concerned about staff misconceptions about pain management and treatment, and that staffers were reacting to pain rather than being proactive.

He educated himself by attending pain management workshops and developed pain assessment tools to be completed on admission, readmission, annually, and in some cases weekly. Because he felt a 0-10 scale left too much room for misinterpretation by staff, he developed a 0-5 scale for both verbal and nonverbal indicators.

Wainman organized training sessions for licensed staff, then followed with monthly meetings for all nursing staff. The nursing staff monitored pain levels in residents during every shift and recorded the data on the Medication Administration Record using the 0-5 scales.

Nursing assistants were taught what information was important to report to licensed staff, using exact circumstances and specific descriptors about a situation. Wainman encouraged staff to determine the relationship of non-verbals to levels of pain and behaviors in those residents unable to express themselves, and then to observe whether regular administration of pain medication or non-medication strategies decreased those behaviors. At training sessions staff were invited to raise questions about specific cases so issues could be discussed. "I became the champion for pain management," he said.

Mark Ballinger, director of nursing at Beatrice Manor in Beatrice, Neb., has a self-described "passion for pain management." He expressed concerns about the absence of consistent strategies, heavy the use of PRN (as needed) analgesics, and occasional disregard for resident pain reports.

He turned to the Internet for help, where he found a wealth of information about pain characteristics, physician and resident viewpoints, treatment strategies, and assessment tools. Armed with data, he assembled a pain management training program for his staff.

Training of nursing staff occurred through a series of monthly meetings. Ballinger reviewed use of the assessment tools, then set a deadline for completion date on all residents. He had an MDS planning checklist developed so assessments would be done in conjunction with each MDS. Facility occurrence report forms were revised to include a required pain assessment.

Successive meetings continued to focus on knowledge of pain and its management. Charge nurses were responsible for teaching nursing assistants how to recognize pain in individual residents. "Now the CNAs (certified nursing assistants) recognize many of the nonverbal indicators of pain," Ballinger said.

Leila Knox, nursing services administrator at Horizon Health and Subacute Center in Fresno, Calif., used a different approach. Her facility joined a collaborative funded by the Centers for Medicare and Medicaid Services (CMS) and formed a pain management committee comprised of nursing staff.

Knox attended training sessions, selected six residents with which to test the program, and met twice weekly with staff to review progress. As the process became refined, more residents were added. Knox selected a 10-point Wong-Baker pain assessment scale was selected for use at admission, quarterly, and sometimes weekly with short-term residents. A separate pain scale was used for nonverbal and comatose residents.

The training continues. Horizon trains all facility staff in pain management. Follow-up in-services happen at least quarterly and during orientation.

Working with physicians

Ballinger adopted a unique approach to secure physician cooperation. After the facility's medical director approved the program, Ballinger sent packets of the training materials to physicians for their review. He requested they discuss the program with other physicians at the hospital staff meeting. "So far we've had good success when we ask for medications in a specific pattern," Ballinger said.

Birchwood nurses educated physicians about the pain management program during rounds. "There was a good working relationship with the local clinic," Wainman said, a factor that enhanced physician acceptance of nursing suggestions for treatment.

Maintaining momentum

Knox and her staff like to celebrate their successes. But if something doesn't work out, they consider it a challenge, then review and revise. The quality indicators from the CMS Web site have improved from 35 percent to 7 percent, and customer satisfaction surveys regarding pain control improved from 75 percent to 95 percent. The facility regularly audits medical records. "We cannot let our guard down," Knox said.

Wainman, who recently became director of nursing at Elim Healthcare and Rehabilitation in Princeton, Minn., used random audits of the Medication Administration Records to help identify situations and staff in need of follow-up. "lf an assessment was done but there was no follow-up treatment, it was easy to pinpoint specific nurses who needed more training." He also reviewed quality indicators that have shown good results, he said.

Ballinger also continues to discuss pain management at staff meetings and in-services and assigns a nurse to monitor for analgesic usage monthly. "We are now focused much more acutely on pain," he said. "Having about 50 percent of residents on an active pain management program is the real success."

A PRESCRIPTION FOR PAIN MANAGEMENT

Dr. David Guay, professor of geriatric pharmacotherapy at the University of Minnesota in Minneapolis and a consultant pharmacist, offered some suggestions for facilities to consider for their pain management programs.

* Use objective methods to assess pain and evaluate treatment response;

* Do routine follow-up soon after initiating treatment or dosage changes;

* Use a small number of analgesics well, rather than a large number poorly;

* Use oral reeds rather than parenteral (injected into the bloodstream) or rectal whenever possible;

* Change to opioids for nonmalignant pain if usual drugs aren't working;

* Combine PRN short-acting oral opioids with maintenance opioids for break-through pain.

The extent of PRN use will guide a need to increase maintenance dose;

* Understand that opioid addiction almost never occurs in a person with pain (exception: pre-existing substance abuse) although dependency does. Never stop "cold turkey";

* Avoid use of NSAIDs unless a compelling reason (e.g. inflammation) exists since they are not particularly safe or effective in the elderly;

* Implement an aggressive stimulant laxative regimen at the start of an opioid regimen;

*Unless contraindicated, use acetaminophen in doses as high as four grams daily for non-inflammatory osteoarthritis before going to "Plan B";

* Use carbamazepine, gabapentin, or lamotrigine for neuropathic pain instead of the more toxic tricyclic antidepressants.

Jan Olson of Woodbury, Minn., is a member of CLTC's editorial advisory board. Retired as director of nursing from the Amherst H. Wilder Foundation in St. Paul, Minn., she is now a freelance writer on long term care issues. Contact her at [e-mail] or [phone].