Joint Commission changes its pain standards
There are five new or revised Joint Commission on Accreditation for Healthcare Organizations (JCAHO) standards related to pain assessment and management, says Darryl Rich, PharmD, MBA.
Rich, JCAHO’s associate director of pharmacy services for Home Accreditation Services, says these changes are effective on all surveys conducted after Jan. 1, 2000. "In the year 2000, they will be scored but will not count toward the accreditation decision or grid score."
The "Rights and Ethics" chapter stresses that under RI.1.1.8, the patient has the right to appropriate assessment and management of pain: "Pain can be a common part of the patient’s experience. Unrelieved pain has adverse physical and psychological effects. The patient’s right to pain management is respected and supported. The organization plans, supports, and coordinates activities and resources to assure the pain of all patients is recognized and addressed appropriately. This includes:
• initial assessment and regular reassessment of pain;
• education of relevant providers in pain assessment and management;
• education of patients regarding their roles in managing pain, as well as the potential limitations and side effects of pain treatments;
• after considering personal, cultural, spiritual, and/or ethnic beliefs, communicating to patients and families that pain management is an important part of care."
Make the commitment
Suggestions to home care organizations for implementing this include putting a commitment to pain management in its mission statement, patient and family bills of rights, or service standards. (For example: "Patients have the right to expect a quick response to reports of pain.")
The following statement on pain management is given to all patients receiving home health services in their admission information packets:
Patient Rights
As a patient of this home care agency, you can expect:
• your reports of pain will be believed;
• information about pain and pain relief measures;
• a concerned staff committed to pain prevention and management;
• health professionals who respond quickly to reports of pain;
• effective pain management.
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Patient responsibilities
As a patient at this clinic, we expect that you will:
• ask your nurse what to expect regarding to pain and pain management;
• discuss pain relief options with your nurse;
• work with your nurse to develop a pain management plan;
• ask for pain relief when pain first begins;
• help your nurse assess your pain;
• tell your nurse if your pain is not relieved;
• tell your nurse about any worries you have about taking pain medication.
JCAHO pain assessment defined
Pain is considered the fifth vital sign. Pain intensity ratings are recorded along with temperature, pulse, respiration, and blood pressure on the home care agency’s flow sheet.
In its initial patient assessment, the home care agency identifies persons with pain or at risk for pain according to criteria developed by the patient care team overseeing pain assessment and treatment. Further assessment is then completed for patients identifying pain or at risk for pain.
All new patients and their families receive information verbally and in an electronic or printed format that effective pain relief is an important part of their treatment. Pain is assessed as a part of every patient contact if the patient reports pain or is at risk for pain.
The organization educates its entire staff, including nursing, pharmacy, home medical equipment, and respiratory care staff about pain, the untoward effects of uncontrolled pain, pain assessment, myths and barriers to reporting pain and using analgesics, and pain management. The organization also formulates a policy and procedure for those patients who report pain receive further assessment and appropriate management.
In the pain assessment chapter, new/revised regulations state that: "In the initial assessment, the organization identifies patients with pain. When pain is identified, the patient can be treated within the organization or referred for treatment. The scope of treatment is based on the care setting and services provided. A more comprehensive assessment is performed when warranted by the patient’s condition. This assessment and a measure of pain intensity and quality (for example, pain character, frequency, location, and duration), appropriate to the patient’s age, are recorded in a way that facilitates regular reassessment and follow-up according to criteria developed by the organization."
To implement this:
All patients are asked on admission the following screening or general questions about the presence of pain: Do you have pain now? Have you had pain in the last several weeks or months? If the patient says "yes" to either question, the organization, based on its scope of practice, either conducts an in-depth assessment or refers the patient for further care.
When clinicians consistently observe discordance between verbal self-report of pain and associated behaviors and ability to function, further assessment is done to ascertain the reason for the discordance. The discordance may be due to a variety of causes, such as stoicism, learned coping skills, expectations about the conditions necessary for adequate analgesia, previous experience that the medication will be immediately discontinued if pain is rated as improved, family dysfunction, or adversarial relationships among the individual, family, and health care team. A home care organization may want to seek out the expertise of an interdisciplinary team to consult on such patients, including representatives from social work, psychology, and chronic disease specialists.
All patients receiving home health services in the initial evaluation are asked the following screening or general questions about the presence of pain: Do you have pain now? Have you had pain in the last several weeks or months? If the patient responds "yes" to either questions, additional assessment data are obtained about the following elements:
• Pain intensity (use a pain intensity rating scale appropriate for the patient population; pain intensity is obtained for pain now, at worst, and at best or least; if at all possible make every attempt to use the same rating scale each time pain is assessed);
• Ask the patient to mark on a diagram or point to the site of pain; and about quality, patterns of radiation, if any, character, using the patient’s own words whenever possible; onset, duration, variation, and patterns of pain; alleviating and aggravating factors; present pain management regimen and effectiveness; pain management history (including a medication history, presence of common barriers to reporting pain and using analgesics, past interventions and response, manner of expressing pain); effects of pain (impact on daily life, function, sleep, appetite, relationships with others, emotions, concentration, and so forth); the patient’s pain goal (including pain intensity and goals related to function, activities, quality of life); and physical exam/observation of the pain site.
• A home care organization decides to use the 0-10 pain scale (0 representing no pain, 10 representing the worst pain imaginable) as its standard measure of pain intensity. However, certain populations may not be able to use this numeric scale, so the organization may need to use other pain scales for special patient populations such as infants and children, older adults, and the cognitively impaired. Developmental stage, chronological age, functional status, cognitive abilities, and emotional status should be considered in the choice of assessment methods and tools. To ensure continuity, the home care organization encourages its affiliated hospitals, clinics, hospice program, and nursing home also to adopt the same pain intensity measures.
• Patients often have more than one site of pain. An assessment system or tools with space to record data on each site is provided on the assessment sheet.
• A home care organization may need to use more than one pain intensity measure. For example, an agency serving both children and adults selects a scale to be used with each of those patient populations. Assessment of cognitively impaired patients may also require assessment of behavioral factors signaling pain or discomfort.
• Staff are educated about pain assessment and treatment including the barriers to reporting pain and using analgesics. Staff encourage the reporting of pain when a patient and/or family member demonstrates reluctance to discuss pain, denies pain when pain is likely to be present (for example, postoperative, trauma, burns), or does not follow through with recommended treatments.
• For organizations using critical pathways or computerized documentation, pain assessment and management is incorporated.
• A home care organization serving children includes in its orientation materials for parents information about pain and pain assessment, including the parent’s role in interpreting behavioral changes of the child that may indicate pain or discomfort.
Patients are educated on the pain assessment process and methods for pain management, as identified in the plan of care.
The goal of patient and family education is to involve patients and families in the management of the patient’s pain. As part of its pain management improvement initiative, a home care agency provides information to all patients and families on admission about the common reasons why patients hesitate to report pain and use analgesics. Based on the reason for admission and the scope of services provided, additional information is given which addresses specific management options and the organization’s policy and process to handle uncontrolled pain or pain management options.
Once is not enough
The literature indicates that, to have the desired effect, patient and family information should be presented more than once, and because patients and families seek information from multiple sources, in more than one way. For patients receiving home health services, specific information included in a comprehensive individual and family education program is as follows:
A. A general overview includes:
— pain can be relieved;
— the causes of pain;
— pain assessment and using a pain rating scale to communicate pain;
— using diaries to record pain occurrences, intensity, times of medication, and relief;
— talking to doctors and nurses about pain and pain management;
— using a preventive approach to pain control.
B. Pharmacological management information includes:
— use of drugs, with specific suggestions to optimize efficacy and safety;
— overcoming fears of addiction (psychological dependence) and drug tolerance;
— controlling common side effects of drugs.
C. Nonpharmacological management information includes deep breathing, relaxation, imagery, distraction, calming self-statements, heat, massage, and exercise.
D. Information about health care system issues includes using effective self-advocacy skills and behaviors in obtaining pain relief.
Scoring and additional information on JCAHO standards changes can be found on the group’s Web site at www.jcaho.org.
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