Creating a cost-effective pain management task force in a community hospital.
Despite advances in pharmacologic, technical, and adjuvant methods, pain remains a common problem for persons experiencing illness and hospitalization. The Agency for Health Care Policy and Research (AHCPR) emphasized the significance of pain as a public health problem with their release of clinical practice guidelines for acute pain management and management of cancer pain. These guidelines indicate that more than half of postoperative patients experience unrelieved pain due to inadequate medication (AHCPR, 1992) and 30% to 75% of all cancer patients report moderate to severe pain (AHCPR, 1994).
The AHCPR guidelines emphasize the importance of a team approach to effective pain management, encompassing patients, families, and health care providers. At the authors' facility, historically there had been an interest, particularly among members of the pharmacy department, in establishing a team to work on improving pain management. This interest coalesced further with the addition to the hospital staff of a clinical nurse specialist with a background and interest in oncology and pain management. This nurse and the clinical pharmacist took the opportunity to jointly attend a Cancer Pain Role Model Conference co-sponsored by the American Cancer Society, New Jersey Division, and the Wisconsin Cancer Pain Initiative. The aim of this program was to form a clinical partnership to improve cancer pain management. An action plan developed at the completion of this program identified the goal of increasing the ability of staff to manage cancer pain appropriately. Action steps identified to obtain this goal were as follows: (a) publicize the release of the AHCPR guidelines throughout the hospital, (b) identify pain management resources within the hospital, (c) form a pain management task force, and (d) plan educational programs related to pain management. The purpose of this article is to describe how the program was planned, implemented, and evaluated and to discuss some important implications of the project.
Implementing a Pain Management Task Force
The first step in forming a pain management group is needs assessment. Informal methods to assess the need for and interest in a group includes discussion among health care professionals with a background and interest in pain management. This discussion can occur both privately and at targeted meetings. A more formal method of assessment is to survey key persons in departments such as nursing, pharmacy, physicians, social service, physical therapy, and patient education.
One-on-one discussion with key persons was the most effective method for stimulating interest and involvement at the project site. A key point in assessment was the first meeting, attendance at which would identify the need for and interest in such a group. Attendance and response at the first meeting were very positive, with all key departments represented. The group was co-chaired by the clinical nurse specialist and the clinical pharmacist. A decision was made to form a task force rather than a committee since the group was assembled to accomplish certain objectives. The group also wanted to avoid any negative connotations associated with the word "committee."
Preliminary objectives were set and approved at the first meeting. These included: (a) identify key people interested in pain management, (b) compile and review pain management resources; and (c) educate health care professionals about pain management. A quarterly meeting schedule was chosen to provide a regular meeting schedule but not overburden the members. Ad hoc groups working on specific projects could meet more often.
Seeking administrative support is an important preliminary step in establishing a pain management group. Due to budgetary constraints it was decided not to pursue a budgeted, staffed pain management team at the time of project planning. Rather, a working task force was established and hospital administration's support was obtained for the goals of the group, meeting space, refreshments, and mailings. Supplies were obtained from the departments in which members worked. Product representatives are an excellent source of support for such a group. They can provide written and manpower supportive resources and funds to help offset the costs of educational programs such as speakers and refreshments. Pharmaceutical companies, hospices, and home health care agencies are all potential sources of support. However, institutional policies regarding the use of these company resources should be cleared with appropriate agency personnel. The task force used company representatives to obtain speakers; however, the hospital provided refreshments, due to administrative preference. Additional resources obtained included pain assessment tools, equianalgesic charts, brochures, and pins for task force members to wear.
Activities of a Pain Management Task Force
An important function of a pain management group is to disseminate information (see Table 1). The pain management task force set as a first priority the distribution of the AHCPR pain management guidelines to all appropriate persons and departments. These guidelines provide not only a concise reference regarding current pain management principles, they also establish an important benchmark for practice validated by a national panel of experts. The guidelines were obtained free of charge from AHCPR. Administrative support was obtained for mailing appropriate guidelines to all physicians on staff. Copies of the guidelines were distributed at pain management task force meetings and were sent to all nursing units, pharmacy, physical therapy, social service, quality assurance, and the hospital library. Members of the task force offered to speak at medical department meetings and brought copies of the guidelines along. A key milestone for the group was being invited to speak about pain management at a department of surgery meeting. To bring attention to the AHCPR guidelines an educational poster display was developed which highlighted the key points (see Table 2). Copies of the guidelines were available at the display and a self-assessment quiz was developed for staff to complete for educational credit. The display was rotated to all clinical areas, the hospital lobby, and the cafeteria.
Table 1. Potential Activities of a Pain Management Task Force 1. Disseminating information, e.g. AHCPR Guidelines 2. Education 3. Policy development/review 4. Quality assurance activities 5. Consultation 6. Case studies 7. Marketing Table 2. Key Points of the AHCPR Guidelines * Interdisciplinary approach important in pain management, include patient and family. * Pain assessment is essential--start with patient self-report. * Utilize a standard pain scale whenever possible, e.g. 0 to 10 scale. * Around-the-clock scheduling is preferred over PRN. * Oral route of administration is preferred whenever possible, if not possible consider IV.
Articles on pain management and the task force were published regularly in the nursing, pharmacy, and physician newsletters. This approach was successful not only in disseminating information but in marketing the task force as a resource for hospital staff. A binder of current articles regarding pain management was also established in the hospital library to provide a quick reference for staff.
Another important function of a pain management group is education of the members and others in the institution. It is essential that group members keep abreast of the latest trends in pain management in order to serve as resources for others (Ferrell, Wenzl, & Wisdom, 1988). Ideas for educational topics were solicited from the task force members and a speaker series was planned. Each educational session had a target professional audience but was also advertised as interdisciplinary in nature. A clinical pharmacist from a hospice presented current trends in pain management, an oncology clinical nurse specialist presented pain assessment, and an oncologist presented an update on cancer pain management. Each of these programs featured a guest speaker to spark interest and included a special luncheon. Attendance and evaluations were overwhelmingly positive. Another way to address ongoing education of the task force members themselves is to include an educational component in each meeting's agenda. To date, these educational sessions have included two case presentations, a discussion of physical modalities in pain management led by the physical therapy department, a presentation on constipation as a side effect of opioids by the clinical nurse specialist, and a session on relaxation therapy led by a psychiatric nurse. Upcoming topics will include pain management in the pediatric population.
One of the preliminary objectives of the group was to analyze what pain management resources--both material and human--already existed within the hospital. Those who have an interest in pain management may not feel comfortable identifying themselves as a resource since this often connotes "expert." For this reason the co-chairs proceeded gently with this project and did not include this as an agenda item until the fourth meeting, although it had been discussed earlier. A resource listing was compiled consisting of persons and departments available for pain consultations, where to obtain copies of the AHCPR guidelines, and resources available in the library including books and videotapes. This resource list was distributed at a meeting of the task force and via the nursing newsletter.
Another area of function for a pain management group is reviewing and developing policies and protocols related to pain management and evaluating the adequacy of products and equipment. The hospital has been using a disposable patient-controlled analgesia (PCA) device for several years. Members of the task force identified limitations with this device and explored currently available PCA technology. A subgroup of the task force selected a PCA pump and coordinated a clinical evaluation. Based on feedback from the staff users, this PCA device was not accepted for implementation. The task force continues to survey the market for another PCA device to evaluate. The PCA flow sheet used for nursing documentation was revised to include a 0-10 pain scale and a revised sedation scale. Standing PCA orders and the PCA policy were also reviewed.
Consultation was identified as a priority by task force members and the co-chairs. As outlined in the pain management resource listing distributed by the task force, several members, including the clinical nurse specialist, clinical pharmacist, physical therapist, anesthesiologist, and oncologist are available for pain management consultations at the request of physicians and nursing staff or other health care providers. A majority of these consults are requested and conducted in an informal manner when a concern regarding pain management is identified by one of the patient's health care providers. The consulted task force member uses an interdisciplinary approach which includes involving the patient, the family, and the patient's nurse. The clinical nurse specialist and clinical pharmacist participate in interdisciplinary nursing rounds on the major medical-surgical units in the hospital. Since this hospital does not have medical residents or medical students, there is no medical team making rounds. The nursing rounds include assessment of appropriate pain management interventions and patient satisfaction with these modalities. The patient's nurse plays an integral role in these rounds and forwards any recommendations or suggestions to the patient's physician. Written recommendations to physicians are also placed in the patient's chart.
Given the current interest in cost effectiveness and patient outcomes, it is important to analyze the results of an interdisciplinary pain group (see Table 3). Ferrell, Whedon, and Rollins (1995) state that gathering data and documenting the current status of pain management are important prerequisites to implementing change. Quality assurance activities are one mechanism to accomplish this. An interdisciplinary quality assessment and improvement study evaluating postoperative pain control was already in the preliminary stages and the task force offered support and consultation. Findings from the study were presented to the task force and to various quality assessment and improvement committees within the hospital. One of the major findings was the relatively high use of meperidine compared to morphine for postoperative pain control. The task force used these data in conjunction with the recommendations outlined in the ACHPR guidelines to educate health care providers at our institution about the advantages of using morphine.
Table 3. Measuring the Impact of a Pain Management Group * Quality assessment and improvement activities * Pharmacy statistics * Patient outcome studies * Patient satisfaction surveys * Research studies
Another source of outcomes data is pharmacy statistics. The pharmacy department compared patient charges for morphine and meperidine for the first 6 months of the current year with the previous year and found that morphine use had doubled, and meperidine use had decreased by approximately 15% when the data were extrapolated to a full year. A similar study is planned for the upcoming year to evaluate the impact of the task force's educational efforts.
Patient satisfaction is a critical measure of the perception of quality of health care services. This measure should be one of the first items addressed in any quality initiative program related to pain (Miaskowski, Jacox, Hester, & Ferrell, 1992). The Joint Commission on Accreditation of Healthcare Organizations is also placing increased emphasis on this type of outcome measurement (Enright, 1988). It is quite possible for patients to obtain great relief from their prescribed pain medication, yet be dissatisfied with the way in which the process was handled by the health care provider. On the other hand, patients who report severe pain often report a high level of satisfaction with their care (Miaskowski, Nichols, Brody, & Synold, 1994; Ward & Gordon, 1994). The AHCPR Guideline for Acute Pain (AHCPR, 1992) emphasizes the importance of determining patient satisfaction at regular intervals. Patients should be asked about current intensity of pain, worst pain experienced in the first 24 hours after surgery, the relief obtained from interventions satisfaction with relief, and the staff's responsiveness. When assessing the results of patient satisfaction surveys it is essential to remember that patients often expect to experience pain after surgery or if they have cancer and will likely rate their satisfaction with pain management on the higher end of the scale. A current goal of the pain management task force is to initiate a patient satisfaction survey regarding pain management and to develop a system for regularly monitoring this aspect of care.
In establishing a pain management group it is important to analyze potential costs. Costs must be considered broadly and all analyses should include supplies, mailings, speakers, and refreshments. Supplies for this group were obtained from the individual departments or through company representatives. The AHCPR guidelines were obtained free of charge. A one-time charge for mailing the guidelines was approved by administration. Refreshments for meetings and educational programs were provided by the hospital, although company representatives are a resource that can help reduce this cost. The overall cost to the institution for the task force's activities in the first year was $1,550--one third of which was a one-time mailing of the AHCPR guidelines. The task force noted that this money was well spent when the positive effects on patient outcomes are considered. In the age of managed care it is also crucial for any pain management group to evaluate the financial implications of pain treatment, especially new technologies (Lagnado, 1996). While there are now many advanced pain management modalities including analgesic patches, PCA devices, and implanted pumps, these can be costly and are not always covered by health insurance.
The experience of this pain management group has validated the importance of an interdisciplinary approach to improving pain management practices. Involvement of physician leaders and hospital staff is essential when the goal is to shift practice toward national guidelines. Administrative support for the group's goals and activities is also a key to success. Financial implications as well as clinical outcomes must be assessed when evaluating pain management.
The pain management task force at this community hospital has been immensely successful in achieving all of its preliminary goals. All of the objectives were accomplished within the first year of the group's formation. At the conclusion of the first year, a summary was compiled highlighting the group's activities including meeting schedule, goals and objectives, educational programs, quality assessment and improvement activities, consultation activities, and marketing of the task force. As long as the task force is functioning, an annual review of the group's mission, goals and objectives, and activities will be conducted to ensure appropriate goals and successful outcomes. The task force was established to fulfill particular goals regarding pain management. As the task force expands its functions and membership, it may develop into a permanent committee. However, as the group evolves, the members of the task force are committed to improving pain management practices at the institution to ensure that patients are as comfortable as possible.
Some suggestions by task force members for future goals include marketing the task force within the hospital and community, planning more educational programs with an emphasis on unit-based inservices, conducting routine patient satisfaction surveys, exploring nonpharmacologic methods of pain management, and increasing involvement of task force members. All of these activities are aimed at facilitating implementation of the AHCPR guidelines and improving outcomes for patients with pain. The efforts of this group show that this can be done cost effectively..
Agency for Health Care Policy and Research. (1992). Acute pain management: Operative or medical procedures and trauma. Clinical practice guideline. AHCPR Pub. No. 92-0032. Rockville, MD.
Agency for Health Care Policy and Research. (1994). Management of cancer pain: Adults. Clinical practice guideline. AHCPR Pub. No. 94-0592. Rockville, MD.
Enright, S.M. (1988). Assessing patient outcomes. American Journal of Hospital Pharmacy 45,1376-1378.
Ferrell, B., Wenzl, C., & Wisdom, C. (1988). Evolution and evaluation of a pain management team. Oncology Nursing Forum, 15(3), 285-289.
Ferrell, B., Whedon, M., & Rollins, B. (1995). Pain and quality assessment/improvement. Journal of Nursing Care Quality, 9(3), 69-85.
Lagnado, L. (1996, August 21). But who will pay for the high cost of relief? Wall Street Journal, B1, B4. Miaskowski, C., Jacox, A., Hester, N., & Ferrell, B. (1992). Interdisciplinary guidelines for the management of acute pain: Implications for quality improvement. Journal of Nursing Care Quality, 7(1), 1-6.
Miaskowski C., Nichols, R., Brody, R., & Synold, T. (1994). Assessment of patient satisfaction utilizing the American Pain Society Quality Assurance Standards on Acute and Cancer-Related Pain. Journal of Pain and Symptom Management, 9, 5-11.
Ward S., & Gordon D. (1994). Application of the American Pain Society Quality Assurance Standards. Pain, 56, 299306.
Susan C. Cobb, MSN, RN, CS, C, OCN, is Director, Education & Clinical Improvement, Graduate Health System -- Rancocas Hospital, Willingboro, NJ.
Sharon A. Mindel, PharmD, is a Clinical Pharmacist and Assistant Director of Pharmacy, Graduate Health System -- Rancocas Hospital, Willingboro, NJ.
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|Author:||Cobb, Susan C.; Mindel, Sharon A.|
|Date:||Dec 1, 1996|
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