Improving Documentation of Pain and Constipation Management Within the Cancer Center of a Large Urban Academic Hospital.

Abstract

Pain and constipation are common among patients with cancer and remain inadequately controlled in many. The Quality Oncology Practice Initiative assessment of pain and constipation at the Georgia Cancer Center for Excellence at Grady Health System identified documentation to be below benchmark levels. A quality improvement initiative to improve pain and constipation management was conducted. Given the low baseline documentation rates for pain (60%) and constipation (20%), we aimed for an increase of 20 percentage points within 1 year. On the basis of cause-and-effect analysis and provider questionnaires to understand fully the causal factors, our multidisciplinary team developed a new provider note template to integrate nurse's assessment of pain and constipation into the provider's documentation. A new order panel was developed in the electronic medical record to link appropriate orders with the pain and constipation plan. The integration of the initial nursing assessment into the provider note template increased pain score documentation from 66.7% to 100% (P < .01), and the pain management plan improved from 65.3% to 86.4% (P = .06). Similarly, constipation assessment documentation improved from 20.4% to 100% (P < .01), and a documented constipation plan improved accordingly from 11.2% to 29.1% (P < .01). As a result of this intervention, pain control at the third clinic visit improved from 61.5% to 86.8% (P < .01). Emergency department visits related to pain and constipation decreased (16.2% to 14.9%; P = .19), and hospitalizations marginally increased (1.6% to 3.6%) during the study period (P =.28). A standardized visit template and hardwired assessment of pain and constipation exceeded the goal for improvement in documentation and positively affected outcomes.