The Common Sense Guide to Improving Palliative Care : Preventing, Assessing, and Treating Pain : Identifying and Testing Changes

Identifying and Testing Changes

Team Faith

To reach its aim, Team Faith eventually chose five changes.

Make pain the "Fifth Vital Sign," which is recorded on admission and on every contact with patient or family.
Change the current pain protocol so that nurses routinely follow up with patients every two hours until the pain goal is met.
Involve physicians and pharmacists in developing preprinted order sets to get escalations of doses to patients promptly.
Have kits of backup medications in the home to cover the most likely escalation of the dose.
For severe pain, be able to have a nurse at the home within three hours.

Team Faith made each change on a small scale by having one nurse try out the new processes on her patients. By testing one change at a time, the team could see which changes led to improvements. When they were satisfied that the change was working smoothly and improved performance, they included more nurses and patients. In the first few weeks, the team was disappointed to find that patient pain measurements were not improving. Team members spent time observing how the changes were being implemented, and they helped the frontline nurses change the workflow so that they had the scale at hand to help patients and families report on pain.

Other successful pain improvement teams have tried changes such as the following.

Eliminate barriers to getting pain medication delivered to patients.

Have a backup physician prescribe drugs if the attending physician is not available within a specific time.

Educate patients, families, and healthcare providers about the nature of opioid analgesics and explain why they are not dangerous.

Make a follow-up call to outpatients two days after discharge to assess the need for a medication change and to prescribe the change by phone.

Post pain scales at each patient bedside.

Give outpatients a pain diary to track pain and the effect of medications taken at home.

Distribute educational materials on pain treatment to patients so that they know what to expect.

Give patients and families a "sure-fire" fallback plan, such as paging the covering physician or house supervisor nurse.

Assess depression and anxiety, especially for patients with pain greater than level five (on a 0–10 scale, see below).

Some patients who have trouble rating pain on a 0–10 scale can use a FACES scale (see Figure 4.2).

Figure 4.2. Wong-Baker FACES Pain Scale. From Hockenberry, J. J., Wilson, D., & Winkelstein, M. L. (2005). <i>Wong's Essentials of Pediatric Nursing</i> (7th ed., p. 1259). St. Louis: Elsevier. Used with permission.

Figure 4.2. Wong-Baker FACES Pain Scale. From Hockenberry, J. J., Wilson, D., & Winkelstein, M. L. (2005). Wong's Essentials of Pediatric Nursing (7th ed., p. 1259). St. Louis: Elsevier. Used with permission.

What Are Some Changes to Try in Managing Pain and Other Symptoms?

Widely accepted guidelines for cancer pain are followed.

Low rate of orders for breakthrough pain (repeated need to treat breakthrough symptoms should trigger increased regular doses of pain medications).

Rescue dose is always available.

When pain is continuous, all opioids are on a regular dosing schedule.

Patients and families control the timing of dosing for breakthrough pain.

Sufficient pain medication is provided during medical procedures and transfers between units and facilities.

On a 0–10 scale, pain greater than three requires intervention; pain greater than six is an emergency). Patient receives emergency response, then root-cause error analysis.

Clinician performance is routinely reviewed, and shortcomings are addressed.

Clinicians attend to and manage predictable side effects.

Patients and families learn about pain management issues from clinicians and staff.

Assess pain, depression, dyspnea, and anxiety on a specified schedule (e.g., admission, change in status, and periodically) 100% of the time.

Use all appropriate modalities, often on time-limited trials, including opioids, non-steroidal anti-inflammatory drugs (NSAIDS), adjuvant analgesics, physical therapy (apply heat and cold), massage therapy, behavioral techniques, steroids, neuroablative procedures, stimulants, and so forth.

Have skilled consultants readily available to patients in all settings (including ICU, hospital, nursing home, hospice, and home).

During transfers between units or sites, prevent pain by holding the sending and receiving parties responsible for being sure that the patient is comfortable and relatively pain free.