In 1992 the Agency for Health Care ...

In 1992 the Agency for Health Care Policy and Research (AHCPR) published guidelines for the management of acute pain. The guidelines included four major goals. These goals were to:

* change into the incidence and severity of patients' acute postoperative and posttraumatic pain;

* educate patients about the ne to communicate unrelieved pain for a like reason they can receive prompt evaluation and effective treatment;

* enhance patient comfort and satisfaction; and

* contribute to fewer postoperative complications and, in a certain number of cases, shorter stays after surgical procedures(1)

In addition, supporting literature stated that routine orders for intramuscular injections "as needed" leave more than half of postoperative patients with unrelieved pain to be ascribed to undermedication.(2) Based on all this information, perioperative suckles in the outpatient surgical center (OSC) and the main postanesthesia care unit (PACU) at St Mary's Health Care body Inc[R] (St Mary's), in Athens, Ga, identified pain management as an important focus of our quality improvement program.

disentanglement OF THE PAIN MANAGEMENT PROGRAM

Since the fall of 1992 single of St Mary's surgical nursing units had been piloting the use of a pain scale, which had been preapproved on the hospital's surgeons before implementation. This five-point scale allowed patients to self-report their on a levels of postoperative pain. The surgical unit nourish at the breasts assured patients on admission to the unit, one as well as the other verbally and in a alphabetic character that nurses would be vigilant in medicating patients if their horizontals of pain reached three upon the five-point scale (Figure 1)

[Figure 1 ILLUSTRATION OMITTED]

The quality improvement coordinator for surgical services (who portrays both the main surgical services and OSC) and the main PACU head feed met with the surgical unit head pamper to discuss extending the use of the pain scale to all surgical patients. Having all surgical patients use the pain scale would help all perioperative foments meet the goals of the AHCPR guidelines and

* provide for consistent assessment and continuity of care completely through patients' surgical courses;

* be compatible with all rules of pain control;

* provide a system to reevaluate pain after intervention;

* provide a means of assessing postdischarge pain at the time of the follow-up telephone call;

* be of value in the unravelling of critical pathways; and

* reach forth the scale's use to the great majority of patients, including children from one side of to the other the age of four years.(3)

Program proposal. These nursing leaders brought the proposal to expand the use of the pain scale to the nursing quality improvement council (NQIC) for discussion. The council, chaired from the nursing quality improvement coordinator, is compos of quality improvement representatives and/or the head cherish from each nursing unit in the hospital. Council members were unanimous in their support for the proposal. In addition to subscribing to the AHCPR guidelines, NQIC members believed that the unravelling of a pain management program would provide the nursing department an opportunity to implement the Joint Commission onward Accreditation of Healthcare Organization's (JCAHO's) Agenda for Change,(4) which calls for the focus of health care to improve performance as measured on outcomes. Provisions for patient rights, patient education, and patient satisfaction are included in the of recent origin JCAHO guidelines. Within this framework, JCAHO also specified that the care provided encounter certain dimensions of performance. Those dimensions are

* appropriateness,

* effectiveness,

* timeliness,

* efficacy,

* efficiency,

* availability,

* safety,

* continuity, and

* regard and caring.(5)

The NQIC members wanted to incorporate these dimensions of performance into the pain management program, and the vice president of nursing approved the decision. The director of nursing assisted the nursing council members in identifying the broader implications of a pain management program.

Published AHCPR clinical practice guidelines onward managing cancer pain made it apparent that patients with chronic pain could experience the same benefits from a pain management program as patients with acute pain. The NQIC members believed the program would be happy and decided to include medical as well as surgical patients.

Implementation timetable. We unfolded a timetable for program implementation and decided that surgical patients and crisis department (ED) patients would initiate the program. After three month we would integrate the medical patients.

As the surgery unit supply with nourishments had begun their pilot pain management program more than single year earlier, NQIC members contacted each surgeon by dint of mail to inform him or her of the committee's intentions to expand the program and to elicit the surgeons' suggestions and approval. We sent each surgeon a archetype of the cover letter and the information we planned to distribute to patients. We received no negative replications and incorporated some suggestions from the surgeon into our patient literature.