One hospital’s journey to improve the patient experience.

Takeaways

• In an effort to improve the state of pain management, nurses in the acute care setting of one hospital developed a plan to supplement traditional pharmacologic treatments with nonpharmacologic interventions.
• A Comfort Menu and Comfort Cart provide patients with nonpharmacologic pain and comfort interventions.

By Ashleigh Anderson, BSN, RN, PCCN, and Amanda Swedhin, BSN, RN, CMSRN

Despite the availability of evidence-based pain-management guidelines, pain remains prevalent among hospitalized patients and is often underreported, underassessed, and under-treated. (See Efforts to address pain management.)

Education programs for staff typically include two standard pain definitions. The first, established by the International Association for the Study of Pain, states: “Pain is an unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage.” The second definition suggests that “pain is whatever the experiencing person says it is, existing whenever the experiencing person says it does.” In other words, a patient’s pain experience involves more than treating an injury and requires multiple treatment options, customized according to individual beliefs and needs.

Unfortunately, most healthcare providers treat pain using pharmacologic methods, leaving nursing staff to find creative, nonpharmacologic comfort measures. Patients have spoken loudly, through satisfaction surveys, that they’re unhappy with the current state of pain management in hospitals. Unrelieved pain produces short- and long-term physiological and psychological consequences, it degrades patient and family quality of life, increases healthcare utilization, drives up healthcare costs, and prevents early discharge.

Pain Champions

At the University of Colorado Hospital (UCH)—a 626-bed, quaternary care, academic medical center—the Pain Champions of Change (UCH Pain Champions) provide leadership, education, and evidence-based quality improvement (QI) pain initiatives. Using the American Pain Society (APS) Patient Outcome Questionnaire (APS-POQ-R), they identified and surveyed 150 UCH inpatients from March 2013 to March 2014 and found that 42% didn’t receive any information about pain treatment options and 65% were never encouraged by their nurse or provider to use nonpharmacologic strategies for pain management.

Based on these results and an extensive literature review on the efficacy of nonpharmacologic pain management, an inpatient charge nurse and a Pain Champion led a QI project to improve patient comfort by developing formalized nonpharmacologic pain-management options on a 36-bed medical-surgical progressive care unit (MSPCU) at UCH. The QI intervention included providing a Comfort Menu and Comfort Cart.

Comfort on the menu

The Comfort Menu lists nonpharmacologic interventions available to the patient and family, such as ice packs, heating pads, massage, music, and aromatherapy. (See The Comfort Menu.)

The Comfort Cart houses some of the items on the menu, including aromatherapy products, distraction tools, earbuds, sleep masks, and massage tools. (See The Comfort Cart.)

Product availability, though, wasn’t going to be enough to improve the patient experience. Staff involvement and understanding of nonpharmacologic pain management was required. Education provided to inpatient care staff, including RNs and certified nursing assistants (CNAs), focused on nonpharmacologic pain interventions and the importance of a comprehensive approach to pain management for improving patient outcomes.

Rising scores

We conducted pre- and postimplementation surveys to ensure nonpharmacologic approaches were being introduced to patients. And to verify that pain management was improved by this implementation, we followed Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) scores related to pain management. We were particularly interested in the question, “During this hospital stay, how often did the hospital staff do everything they could to help you with your pain?”

Initial patient survey results indicated that 83% of patients on the MSPCU experienced pain requiring intervention during their hospital visit and believed that nonpharmacologic methods of pain management would have been helpful. Improvement was noted regarding the percentage of patients who were offered nonpharmacologic options after introduction of the Comfort Menu and Cart. Before implementation, 27% of patients had been offered nonpharmacologic pain-management options; after implementation, 73% had been offered nonpharmacologic options.

The HCAHPS scores also showed progressive improvement in response to the question, “During this hospital stay, how often did the hospital staff do everything they could to help you with your pain?” The responses improved from 72.2% answering “Always” 3 months before implementation to 100% 8 months after. (See Looking up).These data indicate that providing nonpharmacologic options have positively affected patients’ experience of pain management in the MSPCU.

The outcomes of this project were shared with hospital leadership, and Comfort Menus and Carts were rolled out to all inpatient units in the summer of 2016. Initially, the impact was overwhelmingly positive. The nurses loved having easily accessible nonpharmacologic comfort interventions at their disposal, patients responded positively, and HCAHPS scores improved hospital-wide. However, initial positive outcomes have not been sustained. The project has faced ongoing challenges, the greatest of which we believe is making practice change stick and getting the patient care team to make use of nonpharmacologic pain interventions a regular part of their practice. Other challenges include Comfort Cart supply shortages, budget issues, and difficulties with ongoing and new staff education. Currently, the Pain Champions are working on strategies to reinvigorate the project and develop solutions to education and budget challenges.

Changes in federal reimbursement for hospitals since passage of the Patient Protection and Affordable Care Act (PPACA) have highlighted the need to receive patient feedback and input regarding the environment of care and have reignited an urge to improve patient outcomes related to pain management. To support use of the Comfort Menu and Cart throughout the UCHealth hospital system, we planned to present a cost analysis of the products used along with data that measures patient satisfaction and pain experience. However, because of a UCHealth rebranding and significant expansion, this QI project system-wide effort has been placed on a temporary hold.

Tips for success

The success of any pain-management intervention, including a Comfort Menu or Cart, relies on several factors. First, obtain department management support to assist with staff buy-in and to remove barriers. Perform an attitudes and knowledge assessment to gauge staff perspectives and understanding of nonpharmacologic pain-management interventions and guide education. Finally, conduct a literature review to acquire the best evidence about nonpharmacologic pain-management strategies appropriate to a specific patient population as well as the items available on a Comfort Menu or Cart.

To provide intervention structure for a Comfort Menu or Cart throughout the hospital, create a primary task force or group responsible for implementing and maintaining the Menu and Cart, as well as training staff in their use. At UCH, our Volunteer Services Department is responsible for Comfort Menu and Cart dissemination, and the UCH Pain Champions provide staff education and consultation.

How did you make them feel?

Maya Angelou once said, “At the end of the day people won’t remember what you said or did, they will remember how you made them feel.” Making people feel more comfortable is exactly what we set out to do with this project. To positively effect the patient experience at UCH, we surveyed patients, identified an area of care for improvement, reviewed the literature, collaborated with hospital leadership to create a plan, offered an evidence-based intervention, and measured patient satisfaction through direct feedback and a formal survey. Because of MSPCU’s successful outcomes, this intervention was adopted throughout the UCH inpatient setting and will affect thousands of patients. We hope this QI project will continue to have a positive effect on the patient experience and that patients will continue to remember how we made them feel.

Ashleigh Anderson is a permanent charge nurse on the medical-surgical progressive care unit (MSPCU) at University of Colorado Hospital (UCHealth) in Aurora. At the time this article was written, Amanda Swedhin was MSPCU nurse educator at UCHealth.

Selected references

Clarification of the pain management standard. Joint Commission Requirement: Clarification to Standard PC.01.02.07. Jt Comm Perspect. 2014;34(11):11.

Gordon DB, Polomano RC, Pellino TA, et al. Revised American Pain Society Patient Outcome Questionnaire (APS-POQ-R) for quality improvement of pain management in hospitalized adults: Preliminary psychometric evaluation. J Pain. 2010;11(11):1172-86.

Institute of Medicine. Relieving Pain in America: A Blueprint for Transforming Prevention, Care, Education, and Research. June 29, 2011.

International Association for the Study of Pain. Pain terms: A list with definitions and notes on usage. Recommended by the IASP Subcommittee on Taxonomy. Pain. 1979;6(3):249.

McCaffery M. Nursing Practice Theories Related to Cognition, Bodily Pain, and Man-Environment Interactions. Los Angeles: UCLA Students’ Store; 1968.

NIH: The Interagency Pain Research Coordinating Committee. National pain strategy. March 18, 2016.

Pasero C, McCaffery M. Pain Assessment and Pharmacologic Management. St. Louis: Elsevier Mosby; 2010.