Pain management—Continuum of care for surgical patients - Home Study Program

AORN Journal, Sept, 2003 by Sharon W. Chavis, Linda H. Duncan

SEPARATE ANESTHESIA GROUPS. The first major issue identified was that each hospital had a separate anesthesia group and the groups had differing pain management clinical practices. For example, at LGH, anesthesia care providers managed patients until they were discharged from the hospital. At VBH, anesthesia care providers concluded their management of patients after they were discharged from the PACU, which left the surgeon responsible for managing patients' postoperative pain in phase II recovery. These two anesthesia practices created conflicting routines for nurses at both hospitals. Contacting physicians and obtaining orders to medicate patients for pain in a timely manner frequently was a problem. To complicate the issue, individual surgeons varied greatly in regard to pain management and medication preference. No standardized physician order set or protocol for postoperative pain management was available.

NURSING DOCUMENTATION PROCESS. Team members identified both inconsistencies in and lack of required elements in the nursing documentation process. (1) Team members performed chart audits in October 2001 using six standards of measurement that identified specific pain-related issues linked to surgical patients (Figures 1 and 2). It became evident that the available nursing tools and forms were not designed to capture the critical elements outlined in the standards. Chart audits reflected documentation deficiencies in

* education of patient and family members regarding pain management;

* preoperative assessments for pain management;

* use of appropriate pain scales;

* reassessments, monitoring, and interventions to pain management; and

* discharge planning specific to pain management.

STAFF MEMBER COMPETENCY. Team members also determined that staff member knowledge and competency levels in regard to pain management (eg, pain scales, sedation scales, pharmaceutical implications) should be enhanced. This issue was identified through informal needs assessment discussions with staff members. In addition, team members recognized the need to include physicians in the education process by sharing information with them to heighten their awareness and knowledge. Information obtained from a 12-month medication utilization review for surgeons and anesthesia care providers also was shared as an overview of current clinical practice (Tables 1 and 2).

ACTION PLANNING AND IMPLEMENTATION

After agreeing on the key foci for the project, team members began developing action plans to more fully analyze and develop strategies for implementing improved processes, resulting in improved patient outcomes. The PI team developed process improvement action plans for each of the major issues identified. The key issues were consolidated, and priorities were set to include

* documentation,

* patient and family member education,

* staff member education,

* physician orders and protocols, and

* physician education and clinical practice.

DOCUMENTATION. In October 2001, team members performed medical record chart audits to analyze content and the flow of information for six measurement standards. The forms not only lacked the required information, but also failed to support a continuum of care or link the point of care from each surgical area to the next. The following changes were implemented.