There are various ways pain can be measured by hospital staff members, depending on the organization.
At Altru Health System (AHS) in Grand Forks, ND, the patient receives a comprehensive initial pain assessment upon admission. Then every shift thereafter, an ongoing pain assessment is completed.
To ensure that pain assessment and reassessment were happening in patient documents, AHS conducted monthly chart audits.
The data—collected from these monthly chart audits for the Joint Commission Provision of Care standards—revealed low compliance with the need for timely documentation of pain reassessment.
The Pain Management Committee at AHS began revisions of the pain assessment policy after recommendations for policy revisions from Patricia Pejakovich, RN, BSN, MPA, CPHQ, CSHA, senior consultant with The Greeley Company, a division of HCPro Inc., in Marblehead, MA, and Janelle Holth, RN BSN, AHS' regulatory compliance coordinator.
Reassessment for time and policy
Chart audit data indicated that the reassessment for inpatients was occurring, but not documented within the timelines written in the pain assessment policy.
"For example, if a nurse gave a patient medication through an IV, which is supposed to be reassessed within a half hour, it was not happening within that timeframe," says Holth.
AHS has electronic medical records, so even though the nurse was able to reassess the pain timely and document before the end of their shift, the reassessments were not making it back into the records within the required time.
The location of the computers was another complication added to the documentation of pain reassessment within the timelines.
The computers are located in the hallways and not at the bedside, which adds steps to the flow of work processes.
With discussion and clarification of the requirements, the timeliness for reassessment was removed from the policy. This allowed the nursing staff to focus on pain management for the patient, without interrupting the care for the patient.
The nursing staff was also able to reference the time pain was reassessed within their documentation before the end of their shift.
Beneficial options for nursing staff
Now with timelines not a part of the pain reassessment, AHS added other options and opportunities for nurses to document each reassessment they completed.
There are three options available for nurses to choose from when they document pain reassessment:
- A medication tab located under the comments section in the electronic record
- The nurses' notes under the shift-to-shift summary note in the electronic record
- A flow sheet so all medications and times are available to see immediately (this is used more commonly used on the oncology floor)
"The most common method used for pain reassessment is the comments section within the medication tab located in the electronic record," says Holth.
Health system standardization
Once the revision of the pain assessment policy was complete, Nancy Joyner, clinical nurse specialist and co-chair of the pain management committee at AHS, began working on a tool for pain assessment that would be standardized and consistent throughout AHS.
One thing that stood out to Joyner was the fact that there was no non-verbal pain scale.
“With only a verbal pain scale available, nurses did not have a tool to use for the cognitively impaired patient," says Jodi Savat, RN, BSN, OCN.
When dealing with patients who were unable to express how much pain they felt, many nurses were taking an educated guess by using visual cues.
Through research and the assistance of Pejakovich, Joyner developed a comprehensive pain assessment tool. Joyner, Holth, and Pejakovich felt non-verbal pain scales using behavioral and physical signs were most appropriate for AHS.
The tool that seemed the best fit for adults was the Non Verbal Behavioral Pain Scale for Cognitively Impaired Patients. This scale uses a nursing report, not a self-report, and is reflected as such in the nursing notes.
"The nurse looks at the behaviors and vital sign cues and correlates them with a number on the non-verbal scale," says Savat.
"At first it was difficult to decide if the visual and vital sign cues were due to pain or something physiological going on," says Doreen Lindsey, RN, BSN, supervisor of patient care, ICU/CCU.
All the pain assessments are included in a poster that AHS has placed throughout the health system. This makes it easily accessible to any staff nurse, at any point, because the age of patients varies depending on department.