Joint Commission on Accreditation of Healthcare Organizations (JCAHO) Pain Standards: Implications for Clinical Practice Donna Wong, PhD, RN, PNP, CPN, FAAN Copyright, D. Wong, 2003. 2 Impetus for JCAHO Pain Standards The Gap between Knowledge and Technology vs. Clinical Practice 3 NICU Procedures (1997) • • • • Survey of 14 of 38 Canadian NICUs (11-93 to 2-94) Daily logs of procedures/analgesia for 1 week N=239 infants (23 - 42 weeks) Total of 2134 invasive procedures – Heelstick 1298/0 – IV start 451/0 – Venipuncture 179/0 – Umbilical vessel cath 31/0 Cont’d 4 NICU Procedures, cont’d • Analgesia given 17 times for 7 procedures: – Arterial puncture – Et intubation – LP – Peripheral arterial line – Bladder cath – Chest tube insertion – Misc others 88\2 35\2 28\1 6\4 6\1 5\3 7\4 Cont’d 5 NICU Procedures, cont’d • Analgesia given for other reason (eg, surgery) during 129 procedures. • Total analgesia/anesthesia for 6.8% invasive procedures. • Use of analgesia not related to NICU pain protocol. Ref: Johnston C, et al: Clin. J. Pain, 13(4):308312, 1997. 6 End of Life: Pediatric Cancer (2000) • Survey of 103 parents whose child died of cancer (1990 -1997) • Interviews conducted average 3.1 years after death • Focused on quality of life during last month of life • Deaths: 79% from progressive disease 21% from treatment-related complications 49% in hospital; 45% in ICU; almost 50% of those in hospital had ventilator support during last 24 hr Cont’d 7 Parental reports: 89% of children experienced 1 of 4 problems: fatigue, pain, dyspnea, poor appetite • More than 50% suffered from 3 or more of these problems • Pain treated in 76%, successful in 27% • Dyspnea treated in 65%, successful in 16% • Documentation by MDs of symptoms significantly different from parental report • Involvement of hospice: child more calm, peaceful before death; effect on pain control not mentioned Ref: Wolfe J and others: NEJM 342 (5):326-333, 2000 8 Adult Chronic Pain in America (1999) • 56% of 805 individuals with chronic, moderate to severe pain have been suffering for more than 5 years. • 41% report that their pain is out of control; that number rises to 58% among those with the most severe pain (8, 9 or 10 on a scale of 1 to 10 -- with 10 representing "the worst pain imaginable"). Cont’d 9 Adult Chronic Pain in America, cont’d • Among those in severe pain, 46% took over a year to obtain pain relief. • 47% have changed doctors at least once since their pain began. • Almost a quarter--22%--have switched 3 or more times. 10 Adult Chronic Pain in America, cont’d • The primary reasons for changing doctors included: – Patient’s continued suffering (42%). – Doctors’ lack of knowledge about pain (31%). – Doctors’ not taking their pain seriously enough (29%). – Doctors’ unwillingness to treat it aggressively (27%). Ref: American Pain Society, American Academy of Pain Medicine, and Janssen Pharm, 1999. Cont’d 11 Adult Cancer Pain in America (1998) • Survey from computerized database of 1,492 nursing homes in 5 states N=13,625 65 yr or older 4,003 reported daily pain 24% 85 yr or older 29% 75-84 yr 38% 65-74 yr 26% received no analgesia Ages 85 and older received least analgesia Reference: Bernabei and others, JAMA, June 17, 1998. 12 Postoperative Pain in America (1994) • Half of patients given conventional pain therapy--most of 23 million surgical cases/yr have moderate to severe pain. • "PRN" pain control results in prolonged delays because patients may delay asking for help. Cont’d 13 Postoperative Pain in America, cont’d • Aggressive prevention of pain is better than PRN treatment; severe pain is more difficult to treat. • Patients have right to prevention of or adequate relief from pain. • Physicians need to develop pain control plans before surgery and inform patient about pain during and after surgery. • Fears of postsurgical addiction to opioids are generally groundless. Ref: Agency for Health Care Policy and Research, 1994. 14 Practice Guidelines 1992-2001 • Agency for Health Care Policy and Research (AHCPR) • American Pain Society (APS) • World Health Organization (WHO) Analgesic Ladder • American Academy of Pediatrics Statement on Palliative Care for Children • American Academy of Pediatrics (AAP) Statement Prevention and Management of Pain and Stress in the Neonate Cont’d 15 Practice Guidelines 1992-2001, cont’d • AAP Report On Children with Cancer • AAP Report on Assessment and Management of acute Pain in Infants, Children, and Adolescents • American Association of Pain Management (AAPM) and APS use of opioids for the treatment of chronic pain • AAPM, APS, American Society of Addiction Medicine Statement on Definitions Related to the Use of Opioids in Pain Treatment 16 BARRIERS TO EFFECTIVE PRACTICE PAIN MANAGEMENT - Entrenched faulty practices - Unclear roles and responsibilities related to assessing and managing pain - Ultimately, no one held accountable for providing pain relief Joint Commission on Accreditation of Healthcare Organizations (JCAHO) Pain Standards 1. Recognize the right of patients to appropriate assessment and management of pain. 2. Assess the existence and, if so, the nature and intensity of pain in all patients. 3. Record results of the assessment in a way that facilitates regular reassessment and follow-up. 4. Determine and assure staff competency in pain assessment and management, and address pain assessment and management in the orientation of all new staff. 17 Cont’d 18 JCAHO Pain Standards, cont’d 5. Establish policies and procedures which support the appropriate prescription or ordering of effective pain medications. 6. Educate patients and their families about effective pain management. 7. Address patient needs for symptom management in the discharge planning process. 8. Maintain a pain control performance improvement plan. 19 Implementation Strategies According to JCAHO Pain Standards - Include pain treatment in patient bill of rights. - Screen all patients for pain on admission and regularly thereafter. - Ensure competency of staff and physicians in pain assessment and management. Cont’d 20 Implementation Strategies According to JCAHO Pain Standards, cont’d - Ask every patient on admission: “Do you have pain now?” If yes, obtain additional data (Initial Pain Assessment Tool). - Standardize the use of pain scales. Cont’d 21 Implementation Strategies According to JCAHO Pain Standards, cont’d Samples of Pain Rating Scales: • 0-10 Numeric Pain Intensity Scale • Simple Descriptive Pain Intensity Scale • Visual Analog Scale (VAS) • Wong-Baker FACES Pain Rating Scale Cont’d 22 Implementation Strategies According to JCAHO Pain Standards, cont’d For infants and non-verbal children, use appropriate observational scales. “Wong” suggestions are: CRIES (32-60 weeks gestational age) FLACC (fullterm birth – 7 years) Cont’d 23 Implementation Strategies According to JCAHO Pain Standards, cont’d - Monitor all patients systematically for pain intensity and quality and responses to treatment; use comfort-function goal to make treatment decisions. - Incorporate pain in current documentation so that it is visible. - Make pain assessment 5th vital sign. Cont’d 24 Implementation Strategies According to JCAHO Pain Standards, cont’d - Establish interdisciplinary committee or performance improvement team. - Revise formulary and protocols to support research-based practice. - Pilot new analgesic protocols. Cont’d 25 Implementation Strategies According to JCAHO Pain Standards, cont’d - Provide education that gives patients and families knowledge and skills to meet their ongoing pain management needs. - Be sure instruction is presented in ways that are understandable to patients and families. - Include written information. Cont’d 26 Implementation Strategies According to JCAHO Pain Standards, cont’d - Include current pain and strategy for postdischarge pain management in the discharge plan. - Postpone discharge; contact MD if pain is uncontrolled at time of intended discharge. Cont’d 27 Implementation Strategies According to JCAHO Pain Standards, cont’d - Involve clinical units in the collection and analysis of data on staff. performance in pain assessment and management. - Base all decisions on data and current research and recommended practice. 28 Examples of Implementation Strategies According to JCAHO Pain Standards - Minimize meperidine use, DPT for conscious sedation - Reduce use of IM route and PRN orders - Reduce procedure pain, e.g., use of EMLA and buffered lidocaine - Pain ratings > 2/10 require intervention; >4/10 consider opioid - Side effects of opioids are prevented, e.g., constipation (no tolerance develops), N/V and sedation (tolerance develops) Cont’d 29 Examples of Implementation Strategies According to JCAHO Pain Standards, cont’d • Make pain visible - 5th vital signand staff accountable for its relief. • Patient evaluation: How satisfied were you with the amount of pain you had? • How would you rate the way your pain was controlled? 30 Is there legal liability for failure to treat pain adequately? • The verdict is in and the answer is YES. Cont’d Current lawsuits/disciplinary action related to poor pain management • Estate of Henry James v. Hillhaven Corp., North Carolina, 1990; $15 million award to family for compensatory and punitive damages. • Oregon Board of Medical Examiners disciplinary action of physician, 1999. • California’s Elder Abuse case, 2001; $1.5 million award to family. 31 32 The Ten Commandments of Pain Management 1. Thou shalt believe the patient’s report of pain. 2. Thou shalt assess and reassess the patient’s response to pain interventions. 3. Thou shalt not be afraid of prescribing or administering opioid analgesics. 4. Thou shalt not prescribe inadequate amounts of any analgesic. Cont’d 33 The Ten Commandments of Pain Management, cont’d 5. Thou shalt not use the abbreviation PRN for continuous pain, but ATC. 6. Thou shalt reassure the patient and family that risk of opioid addiction is rare. 7. Thou shalt provide support for the whole family. 8. Thou shalt not limit thy approach simply to the use of analgesics, but also adjuvant drugs and “mind-body” techniques. 34 The Ten Commandments of Pain Management, cont’d 9. Thou shalt prevent or treat side effects of opioids. 10. Thou shalt not be afraid to ask colleagues’ advice. Modified from Twycross, R: Practical Palliative Care Today. Spring 2000, Vol. 2. Center for Palliative Studies at San Diego Hospice, San Diego.