Improving Care for the End of Life, Online Edition The Palliative Care Policy Center

Sourcebook : Improving Care for the End of Life : 3.12 Continuously Monitor Pain Treatment Until Acceptable Intensity Is Reached

North Kansas City Hospital

The team at Missouri's North Kansas City Hospital set a broad aim: to routinely assess and control patient pain intensity. The team tried several changes, such as focusing attention on pain assessment on all nursing units, encouraging patient self-reports, and increasing staff monitoring of medical records for pain treatment.

The team also decided to monitor the pain intensity levels for cancer patients in the oncology unit for at least a 24-hour period to assess the duration of pain control achieved through interventions. Data were separated into five categories for pain treatment: patient-controlled analgesia (PCA), continuous epidural infusion (CEI), other types of acute pain control, palliative care pain control, and home health patient pain control.

To measure the effect of changes, four nursing units collected data on two patients each week; pain management services collected data on all continuous epidural patients and on 30 patient-controlled analgesia pump patients per month. The pain level for all oncology patients was to be less than or equal to a score of 3 (on a 0-to-10 scale) following the pain treatment, and 24-hour monitoring of pain control was measured for two oncology patients each week.

The team aimed to have 95 percent of patients reporting pain below an intensity of 3 on a 0-to-10 scale. During the initial project, about 65 percent of patients rated pain at or below 3. The team decided to set a new aim for the current fiscal year: 95 percent of patients will report pain at or below a self-defined tolerance level. During the third fiscal quarter, the team reported that 78 percent of patients were at or below their own pain goal. In cases where pain was not relieved, the team focused on talking with patients and families and working with pain management experts.

Through the quality improvement project, the team learned that process change can be made easier by including it as part of a major quality improvement effort. Physicians in the various units responded to data the team provided and became involved in day-to-day pain management for patients. Eventually, the team helped establish a department-wide pain indicator to meet Joint Commission on the Accreditation of Healthcare Organizations standards for performance improvement. The team said that it successfully raised awareness among nurses on the importance of pain management and has since adopted pain as a fifth vital sign.

The team also found that it was difficult to develop simple, easy-to-follow data collection forms; during the project year, the group revised the forms four times, only to find that some forms still lacked one or more of the necessary elements.

Patients were not always willing to participate in pain treatment, telling nurses they expected to be in pain and, as a result, refusing medication. The team found that ongoing patient and family education programs are essential to changing this perception.

Thanks to the team's efforts, the hospital's board of trustees and the formal subcommittees on pain management, oncology care, and palliative care now receive routine reports on pain management and control.

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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 ].

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