Prior to recent changes in JCAHO’s standards, it was required that hospitals address pain management only as it applies to the care of the dying patient. The newly revised standards, which will be in effect and scored on during the January 2001 survey at BWH, address patients' rights to adequate pain assessment and the treatment across the continuum of care.
The standards apply to both in patient and outpatient areas and require hospitals to:
• Recognize the right of patients to appropriate assessment and management of pain;
• Assess the presence, nature, and intensity of pain in all patients;
• Record the results of the assessment in a way that facilitates regular reassessment and follow-up;
• Determine and ensure staff competency in pain assessment and management and address pain
assessment and management orientation of all new staff;
• Establish policies and procedures that support the appropriate prescription or ordering of effective pain medications;
• Educate patients and their families about effective pain management;
• Address patient needs for symptom management in the discharge planning process; and
• Implement QA procedures to insure effective implementation of initiatives.
At BWH, a nurse and physician are expected to assess all patients upon admission or within 24 hours of admission. During these reviews of the patient’s condition and needs, the pain assessment is initiated. Pain can be measured using a visual or verbal analog scale (VAS score). This is a known as a 10-point scale. For pediatric patients or patients with poor communication ability, a smile face scale may be used. In addition, the impact of pain on a person’s life is an important part of a pain history.
Inpatients may be managed by the BWH Pain Management Service (which is an interdisciplinary service that addresses rehabilitation and psychologic needs as well). This service is managed by the Anesthesia Department and offers medical management of pain in addition to diagnostic and interventional treatments. Consultations are appropriate when pain is difficult to manage, or has been unresponsive to usual medication management.
Reassessment of pain and all other patient conditions is a continuous effort of all care team members. BWH policy designates specific points within a patient stay when reassessment must occur, including:
• Admission;
• Transfer to/from another care unit;
• Post-operatively;
• Significant change occurs in the patient's condition; and
• Discharge
Every patient has the right to pain assessment and management. Patients’ rights regarding pain assessment and management include:
• Initial assessment and regular reassessment;
• Access to providers with education in the area of pain assessment and management; and
• Education for themselves and their families when appropriate, regarding their roles in managing pain as well as the effects of pain treatments
The patient’s health care team has the primary responsibility for Pain Management education to patients and families. There are instances, however, which require consultation from the Pain Management Service based on the patient's individualized care needs.
Current policies regarding the prescription or ordering of effective pain medications are the same as for other medications. Certain specialized delivering systems such as PCA and oral fentanyl lozenge require management by the Pain Management Center's staff. BWH is, however, addressing this question more specifically in the Institutional Policy on Pain Assessment and Management that currently is being developed.
Contact Edgar Ross, MD (ext. 6708) or Catherine Breen, RN (ext. 1334) with any questions.