title: Implementing a pain management program in a long-term care facility using a quality improvement approach.
abstract: BACKGROUND
  Pain constitutes a constant challenge facing staff and residents of skilled nursing facilities (SNF) and nursing homes (NH). Many SNF and NH have not adopted a uniform plan to assess and treat pain for their residents despite published literature that demonstrates that the implementation of scales improves detection and treatment of pain. The objective of this study was to analyze the baseline pain level in the institutionalized elderly, and then implement a standard pain scale for its assessment and evaluation, while simultaneously identifying challenges in adopting this standardized method.
  
  
  METHODS
  As part of a Quality Improvement Project (QI), a total of 40 patients were chosen at random in 2 of the major skilled care and dementia units at a Columbia area nursing home, 20 patients from each. A chart review was conducted to document the presence or absence of pain syndromes, pain medications used, and use of standardized tools for the evaluation of pain. Documentation regarding diagnosis of depression and behavioral problems were also noted as potential markers for the manifestation of pain. Verbal and nonverbal pain scales were introduced and approved by the medical and nursing staff. Training sessions for the administration of such tools were implemented. A baseline evaluation of pain level was obtained applying these newly adopted tools. One cycle using the PDSA (Plan-Do-Study and Act) model for QI was followed.
  
  
  RESULTS
  Our evaluation showed that 84.2% (32/38) of our study population were females, and the mean age was 91.4 years. Fifty percent (19/38) of patients had mild to moderate pain. Because of nonstandardized approaches to analgesia, some regimens rendered clear potential for toxicity: ie, receiving more than 3 grams per day of acetaminophen. Most patients with cognitive deficits had lower levels of moderate pain (9.5% [2/21]) but higher levels of mild pain (33.3% [7/21]) when compared with patients with normal cognition or mild cognitive deficits (35.3% [6/17] and 17.6% [3/17], respectively). Nursing staff adopted successfully the chosen pain tools and gave positive feedback after the trial period, indicating that they were helpful tools to identify pain and treat it promptly. Active participation of nursing staff through the process of decision making, tailoring of the pain assessment scales, and feedback during the period of implementation of pain assessment tools was perceived to facilitate better results. New cycles of pain evaluation and improvement were scheduled.
  
  
  CONCLUSIONS
  Pain evaluation and management is of paramount importance because of its high prevalence and demonstrated deleterious effects on both quality of life and long-term survival. Tools for verbal and nonverbal evaluation of pain are necessary in both NH and SCF. Also, regular cognitive and behavioral assessment may help evaluate pain by providing additional information to physicians, nurses, and other caregivers when treatment becomes more challenging and complex. The use of standard standing orders can easily help decrease the potential of toxicity related to the use of analgesics.
authors.affiliation: University of South Carolina, School of Medicine/Palmetto Health Richland Hospital, Department of Internal Medicine, Division of Geriatrics, Columbia, SC 29203, USA. andyleone@yahoo.com
authors.forename: Andres F
authors.initials: AF
authors.lastname: Leone
authors.forename: Francesco
authors.initials: F
authors.lastname: Standoli
authors.forename: Victor
authors.initials: V
authors.lastname: Hirth
mesh_terms: D000369:Aged, 80 and over; D005260:Female; D006801:Humans; D008297:Male; D008485:Medical Audit; D009735:Nursing Homes; D059408:Pain Management; D010147:Pain Measurement; D011785:Quality Assurance, Health Care; D012866:Skilled Nursing Facilities