By Jason Bramwell
The lack of completed pain assessment documentation at Winchester Medical Center (WMC), Winchester, Va., concerned CNO Kathy Tagnesi.
While nurses were regularly assessing patients' pain, they were not completing the required documentation. A 2009 internal audit revealed that only 66 percent of WMC patients had their pain levels recorded by a nurse within one hour of receiving pain assessments and pain medication-well short of The Joint Commission's 100 percent requirement.
The reason: The pain management workflow was time-consuming and inefficient. Reassessing a patient's pain and manually inputting the patient's pain score in the electronic health record (EHR) took a nurse, on average, nine minutes to finish. "All nurses mean to do it, but they've got a lot on their plates," says clinical manager Susan Clark, RN, MSN.
Asked to develop a more efficient process, Clark and then administrative director Janet Palutke, RN, MSN, came up with a creative solution: Use the hospital's in-room televisions-which are connected to an interactive information, education, and entertainment platform-to enlist patients' assistance in assessing and documenting their pain.
"We thought: What if alert patients could assess their pain levels through a prompt on their TVs, which would automatically notify nurses via pager and document the pain assessment in real time in the EHR?" says Clark.
With the help of IT staff and others, the nurse leaders' idea came to life in 2009. In just one year, the hospital realized a 22.7 percent increase in pain assessment documentation-and, today, the documentation rate sits at just above 90 percent. More important, the hospital has seen a 21 percent increase on certain HCAHPS scores related to pain control.
Clark and Palutke, who retired in 2011, had to complete three steps before the automated pain management workflow system became a reality.
Gaining buy-in from other nurses. Clark and Palutke went before the hospital's Nurse Practice Council to explain their idea for an automated pain management workflow system. The council, which comprises representatives from all nursing departments, meets once a month to review process improvement proposals or rectify issues with how patient care is delivered.
"They felt it was a good process, and we received their blessing," says Clark.
Forming a team to work on the project. The next item on the nurse leaders' to-do list was to enlist the help and expertise of IT personnel and other staff from WMC, parent health system Valley Health, and the interactive patient education system vendor.
"When we can put all the pieces together and create better solutions, it makes for a good working environment," says Kraig Hawkins, integration architect, Valley Health.
Implementation steps ranged from building the drug codes into the existing interactive patient education system and creating a pain-level prompt application to ensuring the hospital's paging and nurse call systems linked with the new technology.
"It was a bit different than anything we had ever done before," says Sheri Shade, systems analyst, Valley Health.
Targeting a pilot unit. The last step was finding a unit in which Clark and Palutke could pilot the automated system. "We thought the cardiac-surgical unit would be best because it has many patients recovering from open heart surgery who are alert and oriented," says Clark.
The automated pain management workflow system was piloted in October 2009 and implemented hospitalwide one month later. The system worked smoothly during the pilot phase-except for one minor hiccup. "We had the prompt set so the pain scale of 0 to 10 popped up on the patient's TV screen one hour after their medication was scanned," says Clark. "However, their pain score didn't chart in the EHR until one hour and two minutes after the medication was scanned. So we made it a 50-minute prompt to get the documentation entered within an hour."
When a patient receives pain medication, the nurse brings in a portable computer that is equipped with a barcode reader. The nurse then scans and administers the medication at the bedside, and assesses and documents the patient's pain, including location, intensity, and type of pain.
Once the medication is scanned, the interactive patient education system is triggered. The system waits 50 minutes before delivering a prompt on the patient's TV screen, asking the patient to rate his or her pain on a scale of 0 to 10. According to Clark, WMC uses the Wong-Baker FACES pain rating scale for adult patients:
"Patients use the arrows on their nurse call bells, which are also their TV controllers, to increase or decrease the number on the TV screen," says Clark. Once the patient finds the number that best represents his or her pain level, they press the enter/select button on the call bell. Their pain score is then automatically documented in the EHR and a message is immediately sent to the nurse's pager.
This approach not only ensures documentation, it also prompts nurses so they can quickly help those patients in distress. Low pain scores of 3 or less do not require nurse intervention, and the nurses can focus on patients with higher scores.
For example, if a patient rates his pain level as "5," his nurse gets a page that says: "Patient in Room 0201 Rates Pain as 5." The nurse then compares the patient's pain level at that time to the pain score documented after the medication was administered.
"If the pain score did not drop, the nurse knows that another intervention is needed," says Clark. "The patient may have only taken one pain pill but could have two, so the nurse would offer the second pill."
If the patient does not respond to the pain-level prompt within 90 seconds, the system sends a message to the nurse's pager that says, "Patient in Room 0201 had NO Response to Pain Rating.""The nurse will immediately know to check on that patient," says Clark. "They like having that little reminder."
WMC's automated pain management process has enabled the hospital to meet its goal of improved efficiency. By eliminating the need for nurses to visit patients with a pain score of 3 or less, Winchester saved 1,526 nurse hours in 2010. "We're just trying to make the nurses' lives a little bit easier," says Clark.
Another positive result: HCAHPS patient satisfaction scores on survey questions related to pain management also increased. For example, the score for question "How often was your pain well controlled?" jumped from 56.7 percent in 2010 to 69 percent in March 2011.
Clark says patients of all ages enjoy using the new technology on their TVs. "The older patients get excited for the pain number to appear. They also like being able to communicate immediately with their nurse," she says. "Their families like how nurses know if their loved one didn't respond to the prompt.
"The younger, technology-savvy patients also love it. They would probably love it more if the pain-level prompt went right to their phone. We're not there yet!" says Clark with a laugh.
Jason Bramwell is associate editor of newsletters & Forums, HFMA (email@example.com).
Interviewed for this article:
Susan Clark, RN, MSN, is clinical manager, Winchester Medical Center, Winchester, Va. (firstname.lastname@example.org).
Kraig Hawkins is integration architect, Valley Health, Winchester, Va. (email@example.com).
Sheri Shade is a systems analyst, Valley Health (firstname.lastname@example.org).
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