Coney Island Hospital is an acute care facility that serves a diverse patient population in Brooklyn, New York. Its Breakthrough Series team aimed to improve pain management through the use of a standard pain intensity scale of 0 to 10. First, the team established baseline measures by informally surveying staff. Nurses, as it turned out, had misconceptions about the use and dosing frequency of pain medications. Almost all patients in a particular unit were on "PRN" (which means "as needed") pain medications, and these patients often waited until their pain intensity levels were very high before seeking relief. Based on these findings, the Breakthrough Series team tried a pain management intervention that offered education and training sessions for professionals and for patients.
Following the training sessions, the team introduced a simple flow sheet for two units to use to document both pain intensity levels and changes in those levels once pain medication was given or increased. In this way, the team found that pretreatment pain intensities for 46 patients were over 7; after treatment, the intensity level dropped to below 5.
The Coney Island team made comprehensive pain assessments part of its change strategy. Other groups may do the same by asking patients about the location of their pain, its nature, its time and course, its duration, and how different treatments have affected it. Simply saying that a patient's pain intensity is a 7 may be accurate - but is not adequate.
Like Coney Island, when the Breakthrough Series team from Kaiser Permanente in San Diego, California, began its project, patient charts had no standardized pain measure. The team began to use a pain flow sheet and assessment tool for outpatients who were dying. Patients were given a pain ruler and then were asked to respond to a questionnaire about their pain. The team made follow-up telephone calls to assess patient pain intensity levels. In this project, 88 percent of patients received appropriate callbacks, and 45 percent of these calls led to changes in the pain management regime. Following the telephone calls and additional visits, 84 percent of patients reported that their levels of pain intensity were acceptable.
Groups can readily encourage patients to think about their own needs for pain control: At what level is pain unacceptable? What is the patient's own goal? What is the lowest intensity level at which a patient will ask for relief? By setting their own standards for pain management, patients can define their own pain scales. Keep in mind, though, that patients are likely to underestimate or underreport pain, that they do not expect much relief from pain, and that they will be satisfied with any attempt to relieve their suffering. \I\Do more than what low patient expectations require!
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This online version of the book Improving Care for the End of Life: A Sourcebook for Health Care Managers and Clinicians is provided with permission of Americans for Better Care of the Dying [ www.abcd-caring.org ] and Oxford University Press. All rights reserved.
For further information on quality improvement in end-of-life care visit The Palliative Care Policy Center [ www.medicaring.org ].