Painless duties: improved pain management plan at your long term care facility.

Pain is one of the primary factors that affect the quality of life. The presence of pain can also affect an individual's behavior, impacting others and resulting in an increased incidence of falls among the elderly. We have acknowledged that pain has a direct impact on a long term are resident's quality of life. We believe that as healthcare providers, we have a fundamental responsibility to those we serve to improve quality of life through staff, resident and family education related to pain and end-of-life issues.

According to the State of Michigan report to Gov. John Engler presented by the Michigan Commission on End-of-Life Care in August 2001, approximately 12 percent of all elderly in the United States live in long term care facilities. Of those people at the end of their lives, approximately 20 percent live in nursing facilities and up to 80 percent of these people suffer from some form of pain.

Within Marwood's 240-bed facility, there are at least 240 opinions of pain. This does not include staff and family interpretations of pain. As the interest for effective pain management became a recognized standard in the healthcare field, we wanted to adapt a pain management program to improve outcomes and quality of life for our residents.

Resident charts, nurse's notes, pain assessment tools, the Center for Health Systems Research and Analysis (CHSRA) quarterly reports, the Minimum Data Set (MDS), resident history and physicals, and a Resident Care Plan (RCP) were utilized to obtain data (Confidential chart information 2000 2002). This data was used to research the effectiveness of the current pain management program.

Serious findings

In 2001, Marwood was asked to become one of the four facilities in the state of Michigan to participate in a pilot program funded by the Robert Wood Johnson Foundation in conjunction with the Michigan Partnership for the Advancement of End-of-Life Care. The goal is to improve pain management in long term care in the state of Michigan.

Our study's population consisted of 25 residents with antecedent complaints of pain, a mixture of diagnosis and a stay of at least 30 days in the long term care facility.

The first series of quantitative data was complied using CHSRA/ORYX reports for three periods: March to December 2000, January to December 2001 and January to December 2002 [see "Process Improvement in Pain Management," below]. Our focus was to analyze the prevalence of quality indicators known to affect quality of life: prevalence of pain, little or no activity, behaviors affecting others and weight loss.

We found a significant decrease in occurrence percentiles in all areas, which coincides with the development of our pain management initiative.

In the second phase of our study, we audited and analyzed quantitative data within documentation in the charts of our survey sample at quarterly intervals for the 2001 calendar year. We examined assessment, documentation and treatment to determine if relief was obtained from a variety of pharmacological and non-pharmacological treatment modalities. Effectiveness of treatment was based upon self-report of relief of pain by the resident and/or non-verbal cues provided by the resident, such as facial grimacing, increased lethargy or crying. Major milestones

Our staff experienced a culture change. At one time it was the nurse's responsibility to assess and manage pain. With the education of our non-nursing staff (housekeeping, maintenance, activities, social work, and office staff) in basic pain assessment skills, the responsibility now belongs to all of our staff.

Education about pain and pain management with residents and their families was imperative in the development of our personalized pain management program. Residents are now actively encouraged to participate in their care. Residents who are reluctant to report pain are reassured that there are many safe and effective ways to relieve pain.

The Clinical Pain ManagementTeam--made up of two nurses, a social worker and a pastor--was developed after a staff survey showed that communication was the biggest barrier between disciplines when reporting pain. For staff members who feel that the reporting of pain is not being addressed, they are able to make a confidential referral to the team. The team then reviews the resident's chart and speaks with the nursing staff to ensure that pain is being addressed.

As we monitor the quality indicators known to affect quality of life, we have seen a significant percentile decrease [see "Critical Success," above]. These improvements coincide with our pain management initiative.

ABOUT MARWOOD

Marwood Nursing and Rehab, a 240-bed, not-for-profit facility in Port Huron, Mich, is one of five healthcare organizations in the nation to receive the 2002 Ernest A. Codman Award. Marwood received this award for the Long-Term category by the Joint Commission on Accreditation of Healthcare Organizations. The award recognizes excellence in the use of outcome measurements by healthcare organizations to achieve improvement in the quality and safety of healthcere. The facility earned the award for an initiative that resulted in a decrease in chronic pain among its residents from 33 percent in March 2000 to 23 percent in December 2001 and 18 percent in December 2002. This reduction is significant given that the assessment of an individual's response to pain is highly complex, particularly among the elderly who may have cognitive deficits or communication deficits.

Process Improvement in Pain Management
Statistical Analysis of Quality Indicators

                             Mar '00-   Jan '01-   Jan '02-
                             Dec '00    Dec '01    Dec '02

Weight Loss                   13.4        8.5        9.3
Behaviors Affecting Others    32.1       21.4       13.6
Little/No Activity            13.5        9          7
Prevaience of Pain            31.9       22.9       18.1

Source: CHSRA reports March 2000-January 2003

Note: Table made from bar graph.

Critical Success

Pain                               39.6%
Little or no activity              25.8%
Decline in range of motion         63.8%
Daily physical restraints          34.5%
Falls                              19.3%
Behaviors affecting others         24.5%
Signs and symptoms of depression   42.0%
Weight Loss                        29.8%
Decline in late loss ADLs          39.1%

Suzanne Walker, R.N., has been employed at Marywood Nursing and Rehab since 1996 in a variety of roles including staff nurse, infection control coordinator and clinical coordinator. She is actively involved in the advanced training of nursing staff in the Pain Management Iniative.