A multi-disciplinary algorithm for pain management in radiation oncology

Abstract

Purpose: JCAHO standards (2000) for pain management are designed for hospitals, long term care facilities, outpatient centers and home care. Historically studies have focused on the quality of inpatient pain management. Miaskowski, Pain Management Nursing, March 2001, identified the need for further evaluation of pain management in outpatient facilities. In radiation oncology daily visits allow for continuity of pain/symptom assessment. We hypothesized that improvement in quality of care could be achieved through education and the promotion of staff and patient awareness regarding pain. A multidisciplinary approach was proposed and a plan developed. The plan included staff education, following an initial assessment of knowledge, and patient education. Tools for clinical documentation, QI assessment and satisfaction questionnaire were developed in compliance with JCAHO standards. Materials and Methods: Radiation Oncology physicians, nurses and therapists completed the McCaffery Knowledge and Attitudes Survey. Educational sessions were presented based on the outline developed by Ferrell, Grant and Viani, City of Hope. Post-tests were administered at the end of each segment to assess learning. Chart audits using a modified McCaffery/Pasero tool were performed prior to beginning the study. Ten charts were audited (10% of patient population) to assess documentation of pain and to serve as baseline data. A systematic approach was developed for the evaluation, assessment and reassessment of the patient with pain management issues. Initial assessments are completed and documented on all patients seen in radiation oncology. These include pain intensity, location, quality of pain, patterns of pain, aggravating and relieving factors, pain management regimen, associated symptoms, effect of pain on activities of daily living and the patient’s pain goal among other items. Patients reporting pain had their chart identified. The therapist records the patient report of pain and bowel function on a flow sheet by at each visit. Increased pain report results in the notification of the nurse. Nurses routinely reassess pain weekly and intervene immediately if there is a new report of or an increase in pain. Nurses notify the CNS if there are difficulties managing pain. The CNS performs a complete pain assessment and in collaboration with the physician develops a plan of care. If the pain continues to be unrelieved the patient is referred to a pain management specialist. A patient/family education program “Pain-Let’s Talk About It” is offered quarterly. The patient satisfaction questionnaire, modified from McCaffery and Pasero, is distributed to those patients who receive pain intervention. Results: Knowledge and Attitudes Surveys completed three months after the educational component demonstrated increases in and retention of knowledge. A follow-up chart audit performed in January (10% of active patients) demonstrated improvement in the areas of initial patient assessment, therapist use of scale, nurse’s use of scale and the setting of comfort goals. Results of the patient satisfaction questionnaire thus far indicate that this subset of patients is very satisfied with their pain management. An unplanned outcome was the modification and adoption of the radiation oncology bowel protocol as a systemwide standardized protocol for inpatients, outpatients and home care/hospice patients. Conclusion: There has been improvement in pain/symptom management in Radiation Oncology. Currently we are modifying the pain documentation tool to reflect a graph format including the disease site, radiation site and RN referral dates. Future plans include the evaluation of the number of referrals to the RNs and CNS. Self learning modules on pain will become a mandatory part of the orientation process. At the request of the managing physicians the CNS will dictate pain consults and send them copies for their records, rather than keeping them infromed via phone messages. Plans include an assessment of patient satisfaction regarding pain assessment in the patient population not receiving pain interventions, with a comparison of this subset to the intervention group.