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.
Have a physician champion lead the pain-management improvement effort, to ensure buy-in from staff at all levels.
Involve the entire care team in designing solutions.
Pilot solutions in one area or unit, and then expand them to other units.
During the expansion phase, balance one-size-fits-all with unit-specific approaches.
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.
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.
Physicians, resident physicians, nurses, nursing aides, pharmacists, social workers, and improvement specialists were involved.
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:
- 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.
- Establish protocols for consultation with the Acute Pain and Palliative Care services.
- Create patient-education brochures that highlight non-pharmacologic pain management.
- Engage all staff members in pain-management efforts, and assess those efforts.
- 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.
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.
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.
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/
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