Care Redesign

Pain Management for Inpatients: A Multidisciplinary Team Approach

Case Study · August 12, 2016

University of Utah Health Care implemented a team-based, multidisciplinary intervention for managing the pain of inpatients. Led by a physician champion, the effort was piloted in one acute-care unit and then expanded to other units. Pain-management measures show modest improvements, and staff members (including physicians) report that they have become more skilled at and committed to managing patients’ pain.

Key Takeaways

  1. Have a physician champion lead the pain-management improvement effort, to ensure buy-in from staff at all levels.

  2. Involve the entire care team in designing solutions.

  3. Pilot solutions in one area or unit, and then expand them to other units.

  4. During the expansion phase, balance one-size-fits-all with unit-specific approaches.

The Challenge

Across the University of Utah’s acute-care units, pain-management scores were extremely low — in the fifth percentile in 2012 and 2013, according to Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) measures. The burden for patients was obvious, and clinicians felt powerless. Pharmacologic solutions frequently fell short, non-pharmacologic options were few, hospital staff often lacked skill in managing patients’ pain, protocols and standards for pain management were thin, care teams did not coordinate with one another, and involvement of specialists was limited.

The Goal

In 2014, Dr. Nathan Wanner, Director of the Hospitalist and Palliative Care Service, decided to make patient-centered pain management a priority. He collaborated with attending physicians, residents, nurses, nurses’ aides, pharmacists, social workers, and improvement specialists to expand competency in pain management. The goal: Meet patients’ needs within the realistic constraints of staff workflows.

The Team

Physicians, resident physicians, nurses, nursing aides, pharmacists, social workers, and improvement specialists were involved.

The Execution

Dr. Wanner started by surveying nurses, residents, and hospitalists about their attitudes toward pain and opioid abuse. The survey results documented a wide range of attitudes among staff and very little use of non-pharmacologic approaches to pain management. Caregivers’ well-intended desire to minimize opioid use sometimes made them unwilling to prescribe appropriate pain medications. Occasionally, relationships with patients became antagonistic.

Wanner provided the residents and hospitalists with guidance on when to consult the hospital’s Acute Pain and Palliative Care services. He also developed a patient-education brochure, “My Pain Management Guide,” that answered patients’ frequently asked questions and outlined alternatives to medications, such as hot and cold packs, pet therapy, physical positioning, and comfort items (e.g., saline nose spray and ear plugs). Most important, the guide featured a log for patients and nurses to track their conversations about pain in a structured and comprehensive way. Pharmacists and social workers also offered medication-management support and mindfulness coaching to patients.

A working group on a nursing unit engaged bedside nurses to design a pilot pain-management workflow. Feedback, given by all team members, uncovered many opportunities for efficiency and team-based coordination. This effort revealed, for example, that nurses’ aides were underutilized, so the process was redesigned to increase their role in pain management.

Wanner and the nursing leadership expanded the improvements to other nursing units. They focused on five key elements:

  1. Meet with physicians to discuss the value of a team-based approach to pain management — one that involves partnering with nurses, pharmacists, social workers, nursing aides, and trainees.
  2. Establish protocols for consultation with the Acute Pain and Palliative Care services.
  3. Create patient-education brochures that highlight non-pharmacologic pain management.
  4. Engage all staff members in pain-management efforts, and assess those efforts.
  5. Institute a team-based process to escalate tough patient cases to consulting services (Acute Pain, Palliative Care, Pharmacy).

Wanner himself leads the physician-engagement effort. It challenges old norms, makes physicians aware of and responsive to patient feedback, and seeks ongoing improvements to the system.

The Metrics

HCAHPS Pain Management domain questions (on pain control and on the metric “Staff do everything to help with pain”) were assessed.

From 2012 to 2015, the percentage of patients who reported (on the HCAHPS pain-control question) that their pain was always controlled has risen by only 0.2%. However, the percentage of patients who indicate that staff “always do everything to help with pain” has improved by 4.2% (from 70.4% to 74.6%), as shown in the graph.

wanner01_case_graphic_PUBLISHED_20151125

Today, in 2015, the HCAHPS pain-management scores for the University of Utah’s acute-care units are at the 38th percentile, up from the fifth percentile in 2012.

In internal surveys, physicians indicate that they now have more non-medication options, more overall support, and more-consistent processes — and that they can provide better overall pain care than they did before the intervention. The percentage of hospitalists who describe difficult pain cases as a major obstacle to job satisfaction has decreased dramatically (from 50% to 13%).

Where to Start

Engaging physicians and nursing teams was key to creating momentum for change. When starting conversations with new groups, we suggest asking these five questions (which Wanner posed to our staff):

  • What are your greatest frustrations around pain management?
  • Where do you think the team could use help?
  • What features and principles should a great pain-management system have?
  • How can your pain-management system be made easier and more automated?
  • How do the system’s resources fail to promote pain-management best practices?

Answers to these questions revealed that our pain-management approaches were not standardized, that we specifically lacked protocols for responding to challenging patients and for other difficult situations, and that our patient-education efforts needed to be consistent, both in face-to-face and written (e.g., brochure) communications.

Next Steps

We have set three primary goals in our commitment to ongoing improvement:

  • Improve the ratio of nurses’ aides to patients from 6:1 to 5:1, with an emphasis on increased bedside-care responsibilities and non-pharmacologic pain management.
  • Have 100% of social workers using mindfulness techniques in their work with patients on pain management. (We also recently started a study of the effect of mindfulness interventions on patients’ perceptions of pain.)
  • Offer physicians and advanced practice clinicians education in pain management, with a focus on better communication with patients about pain. (Participation is voluntary, although all classes to date have been filled and demand continues to grow.)

 

This article originally appeared in NEJM Catalyst on November 25, 2015. Additional contributors include: Laura Adams, MSN, Director of Acute Care Nursing; Lana McGill, MD, resident; Claire Ciarkowski, MD, resident; Devin Horton, MD, Clinical Instructor. Support for this article was provided by a program grant from the Robert Wood Johnson Foundation: http://healthsciences.utah.edu/value-university/

 

How has your hospital improved pain management? Share your experiences in the “Discuss” section below.

Call for submissions:

Now inviting expert articles, longform articles, and case studies for peer review

Connect

A weekly email newsletter featuring the latest actionable ideas and practical innovations from NEJM Catalyst.

Learn More »

More From Care Redesign
Murali01_pullquote Home Recovery Care patient satisfaction

No Place Like Home: Bringing Inpatient Care to the Patient

Providing home-based acute care improves patient satisfaction and care quality while reducing costs.

Rating the Raters - Strengths and Weaknesses Assessment of the Four Public Hospital Quality Rating Systems - 2a

Rating the Raters: An Evaluation of Publicly Reported Hospital Quality Rating Systems

Some promising innovation is taking place among organizations that rate hospital performance, but major systemic change is needed in the field to ensure access to meaningful comparisons through better data and relevant metrics, and to establish integrated oversight through robust audits and peer review.

McKee01_pullquote - the need for coordinated care IPUs for Parkinson's disease

Creating “One-Stop Shop” Care for Parkinson’s

Integrated Practice Units (IPUs) can revolutionize the care of specialty disease conditions, and Parkinson’s disease is a good place to start.

Good Shepherd culturally competent hospice care home visit to the widow of a recently deceased patient

Strangers No More: Culturally Competent Add-On Programs for Diverse Seniors

Creating specialized culturally competent programs to improve patient satisfaction and address the unique health care needs of older immigrants.

Kimberly Dennis and David Newton head shots - SunCloud Mental Health Services

Addressing the Lack of Continuity of Care in Mental Health Services

Co-founders of an integrative outpatient treatment center for mental health and addiction discuss the problematic lack of continuity of care between inpatient and outpatient and physical and mental health services.

Epic OB Hemorrhage PPH Risk Assessment Tool and Alerts at PSJH - Preventing Maternal Death

Improving Maternal Safety Through an EMR Risk Assessment

After a mother died of postpartum hemorrhage, Providence St. Joseph Health made organization-wide changes to prevent future maternal deaths and injuries.

Most Health Care Organizations Have Palliative or End-of-Life Care Programs

Survey Snapshot: Challenging the Resistance to “Palliative”

NEJM Catalyst Insights Council members agree that palliative care is gaining traction, but one of many barriers is getting providers over their resistance to the word “palliative.”

The Assessment of Care Tool - Consisting of Six Visual Analog Scales Corresponding with the IOM Six Dimensions of Perfect Care

Real-Time Pursuit of Outcomes That Matter to Patients

A simple and affordable tool to use at the point of care to drive value creation within clinical microsystems.

Many Patients Who Would Benefit from Palliative - End-of-Life Care Do Not Receive It

Care Redesign Survey: The Power of Palliative Care

Our NEJM Catalyst Insights Council survey on palliative care reveals an interesting dichotomy: While the great majority of organizations have a palliative or end-of-life care program, 60% of patients who would benefit from such services don’t receive them.

Heart Safe Motherhood and Way to Health Two-Way Texting for Blood Pressure Monitoring for Postpartum Women with Preeclampsia

Heart Safe Motherhood: Applying Innovation Methodology for Improved Maternal Outcomes

At the Hospital of the University of Pennsylvania, a text message–based blood pressure surveillance program for postpartum women with preeclampsia improved blood pressure management, reduced readmissions, and increased patient and provider satisfaction.

Connect

A weekly email newsletter featuring the latest actionable ideas and practical innovations from NEJM Catalyst.

Learn More »

Topics

Coordinated Care

141 Articles

Creating “One-Stop Shop” Care for Parkinson’s

Integrated Practice Units (IPUs) can revolutionize the care of specialty disease conditions, and Parkinson’s disease…

Physician Incentives: Importance of the Why

When moving health care providers forward in the world of value-based care and population health,…

Primary Care

196 Articles

No Place Like Home: Bringing Inpatient…

Providing home-based acute care improves patient satisfaction and care quality while reducing costs.

Insights Council

Have a voice. Join other health care leaders effecting change, shaping tomorrow.

Apply Now