Pain has long been one of the primary symptoms for which patients seek healthcare. Organizations provide various treatment modalities in an attempt to alleviate pain. These interventions include surgery, physical therapy, medication, and psychotherapy options, to name a few. Under §482.21 Condition of Participation: Quality Assessment and Performance Improvement Program, the Centers for Medicare and Medicaid Services (CMS) requires organizations to “monitor the effectiveness and safety of services and quality of care.”[i]
Our consultant teams consistently find opportunities for pain medication practices during survey. The majority of our observations focus on the administration of medications for pain control. Our top findings include issues with incomplete medication orders, missing pain assessments before/after analgesia administration, care plans not including pain as a problem, and medication administration not occurring according to order. When the organization is asked to provide the analysis of their data on pain management, their review is often limited in scope and depth of review. Predominately, organizations are focused on pain assessment/reassessment instead of including a more robust review of their program to fully determine if they are meeting the pain management needs of their patients.
Have you reviewed the quality assurance monitoring of your pain medication practices? What is your data showing? Does it provide a full picture of your organization’s pain medication processes? Our discussion will provide some considerations as you dive into your program’s performance.
Understand Your Pain Management Processes:
Organizations need to understand where their pain medication processes occur and the elements of each. Pain medication administration may vary from the Emergency Department to Inpatient Nursing Units, Outpatient Clinics, and Perioperative spaces. Leaders should consider mapping these processes to identify vulnerabilities and potential safety risks and develop both action plans and monitoring plans based upon the outcome. We must ensure that all aspects of the pain medication process are included, from ordering the medication and dispensing the medication to the administration and monitoring for effectiveness of the intervention.
Risk management reports can be a treasure trove of information, depending on the amount of reporting that occurs within the organization. Medication errors and near misses with pain medications may give some guidance on specific hot spots for ongoing monitoring. Assessing for pain medication errors/near misses reporting rates can provide an excellent data source for process improvement activity.
Audit Criteria for Consideration:
Monitoring your pain management program must align with your accrediting organization’s requirements. Be aware that local and state requirements may also exist. Based on our observations from the field and review of best practices, here are some considerations of program review elements:
- Orders Contain Required Elements: A review of pain medication orders should be made to ensure that all required elements are included, such as the name of the medication, route of administration, dosage, frequency of administration, reason for administration if providing PRN. Our teams are continuing to find opportunities with provider orders for pain medications.
- For titratable pain medications, additional elements would include the initial or starting rate of infusion (dose/min), the incremental units the rate can be increased or decreased, the frequency for adjusting incremental doses, the maximum rate (dose) of infusion, and the objective clinical endpoint (such as RASS score).
- Review for therapeutic duplication orders. Is there clarification in the order for precedence of administration?
- Pharmacy Review of Orders: Auditing the pharmacy process of reviewing provider pain orders should be considered part of the pain management program review. Our consultant teams have found frequent observations where provider orders did not contain all of the required elements and were not identified and clarified by the pharmacist. This step is one of the essential safety checks before administering any medication inclusive of pain medication and must be validated as reliable.
- Pain is Addressed in the Care Plan: Care plans are the backbone of patient care, as such they must accurately reflect the patient's needs. Our consultant teams have repeatedly found care plans do not mention a patient’s pain issues.
- Pain Goals: Assessing your patient for pain is a critical element of patient assessment. How is your organization assessing the patient in pain for their desired pain goal to be achieved during treatment? Patients with chronic pain may feel comfortable with a goal of 2 or 3, whereas others want zero pain. Patients unable to articulate their pain must be assessed for non-verbal cues. The goal is a destination of therapeutic intervention. Without a goal, healthcare teams will not know when the interventions have been effective. We most frequently observe a lack of goal setting with analgesia administration. What does your team do when, after administration of pain medications for 10/10 pain, the patient reports a pain level of 6? There is no goal, and the patient orders provide no direction as to next steps. We frequently find that organizations do not close this loop.
- Patient is Administered Medications As Ordered: Organizations should ensure that review of medical records includes validating that staff have administered pain medications as ordered. These findings can identify if staff are operating outside of their scope of practice, which can be a serious patient safety issue.
- Our teams are finding where patients are provided medications for pain less than their assessed pain level. This is permissible if policy/orders support this practice and there is documentation that the patient chose the lesser potent agent.
- We have noted patients receiving more potent pain medication than their assessed pain level with no supporting orders.
- Do your patients on titratable medications have documented changes in their infusion per the order? Was the medication infusion started at the prescribed rate? Are frequencies of changes in accordance with the order?
- Patient is Assessed For Pain: As mentioned above, many organizations monitor and report pain assessment/reassessment practices. Gathering meaningful information from the patient can be a challenge when language barriers exist. Consider evaluating the use of translation services for pain assessment for patients with English as a second language. Are staff using non-verbal assessment tools correctly for patients who cannot articulate pain? Again, if a patient is assessed for pain after medication administration and does not reach their pain goal, are staff addressing this?
Data Analysis:
Organizations should ensure that, even with robust data streams from process activities, they conduct thorough reviews and analyses to identify trends and opportunities. Organizations frequently state, “We monitor our pain reassessment process.” However, what has the data shown? Are there trends? Are we meeting goals? Have we even set individual patient goals? Where are there opportunities? Where are we exceeding our expectations? Have we validated the data? Are we using inter-rater reliability to validate our results?
Detailed data display, including run charts, can provide a visual story for the organization (and the survey team) that can greatly assist in understanding where opportunities lie. Drilling down to the unit, department, provider, nurse, and medication can allow organizations to better direct improvement efforts. The use of digital records can make this possible, and organizations should query their electronic medical record provider to see if they have pre-designed reporting available. However, organizations without robust documentation platforms can use paper-based audit data and aggregate it into a database that can be filtered to provide information for data analysis.
Keep in mind that data collected to the individual prescriber level can also be used as a component of your physician evaluation process or OPPE program. If your data allows you to identify opportunities to the level of the person administering the medication, this too can be used for individual staff performance evaluations.
Summary:
Organizations must ensure that the evaluation of their pain management program, especially with pain medication interventions, is robust enough to provide a full accounting of their practices. Audits should be designed to monitor those critical and safety risk components and drive changes when opportunities are found. This will serve the organization well in its commitment to patient safety and effective pain control.
[i] State Operations Manual, Appendix A - Survey Protocol, Regulations and Interpretive Guidelines for Hospitals. The Centers for Medicare and Medicaid Services. 4.19.24.
For questions or to learn more contact the C&A team at 704-573-4535 or email us at info@courtemanche-assocs.com.
