Patient and provider education alone will not be sufficient to create widespread change in an institution's pain management practice. Institutional change tends to come on the heels of institutional commitment, a public statement or promise that pain management is a top priority.
One pain management consultant (Super, 1996) has reported on a quality improvement project she and her colleagues undertook at an urban medical center in Portland. When the project began, patients had an average pain intensity level of 6.3 on a 0-to-10 scale. In an effort to reduce this intensity level, 850 nurses participated in 23 mandatory four-hour classes; more than 100 physicians, social workers, pharmacists, and administrators also participated. After this huge educational effort, the mean pain score dropped to 5.7 - still a poor level.
The administration decided to make pain management improvements an institutional objective. Patient documentation was revised to include baseline assessment and routine reevaluation of pain intensity. At this point, the mean pain rate fell to 3.2. Signs were posted in every patient room to tell patients and families to expect pain relief and to report unrelieved pain. The mean rate continued to fall, and in 18 months it had reached 2.3!Balm of Gilead Center
During the Breakthrough Series, the team from Cooper Green Hospital, a public hospital serving Jefferson County, Alabama, created the Balm of Gilead Center in Birmingham to provide hospice services to poor and indigent community members. As it worked to make pain management an institutional priority, the team:
Patients actually began to use the pain intensity rulers to communicate about other problems. When asked to point to the number that represented her pain, one patient pointed to one number and said, "My pain is here," and then pointed to another number and said, "And my anxiety is here."
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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 ].