Long-Term Care Survey Alert

Published on Thu Jan 10, 2013 PDF

Artful pain assessment will give a true picture  of residents experiencing uncontrolled pain in your facility. And a state-of-the art pain management program should help ease those complaints and portray your nursing facility in a good light on the upcoming pain quality measure.

Yet facilities that use pain management protocols that “rescue” residents from pain by allowing it to get bad enough for the resident to ask for a PRN medication that provides only temporary relief.

“The preferred approach is to prevent pain with round-the-clock medication, if possible, and other interventions,” explains Cheryl Field, a consultant in Bedford, MA. “Then you provide medication for ‘breakthrough’ pain.”

The facility should also provide pain medication in anticipation of times when the resident is likely to suffer severe pain. “You medicate the resident before he goes to the gym if he complains that exercise causes” him serious pain, Field suggests.

Don’t Fear Polypharmacy

Fear of polypharmacy can be stumbling block to effective pain management. “Long-term care staff has been taught by the quality indicator system to try to limit drugs to one per diagnosis,” Field notes. So staff gets worried when the total number of drugs begins to climb near nine, which means the resident will trigger a QI. In such a case, the physician should document the rationale for the resident receiving the extra medications to control pain.

“So they don’t prescribe more than one pain medication for arthritis, for example,” Field says, when a second pain medicine could provide better pain control. “There is polypharmacy that is ineffective and some that is very good at managing pain by using a combination of medications — for example, one that targets inflammatory pain, another one for neuropathic pain, and a third one to provide analgesia.

“You also have to ensure the resident receives therapeutic dosages,” Field emphasizes. “Sometimes a resident will be on four medications for pain and none is at a therapeutic level.”

Some long-term care clinicians shy away from use of opiates to treat serious pain due to concerns about addiction, side effects in the elderly — or the stigma associated with narcotics.

According to the American Geriatrics Society’s new pain guidelines, however, “continuous opioid therapy or some other analgesic strategies may have fewer life-threatening risks than do the long-term daily use of high-dose NSAIDS.”

The AGS guidelines also say that opioid drugs may be the correct pain reliever when a patient is suffering from severe pain, particularly those near the end of life. AGS President Jerry Johnson  says that “the incidence of addictive behavior among patients taking opioid drugs for medical indications appears to be very low.” Johnson says he predicts the AGS pain guidelines will help the Centers for Medicare & Medicaid Services evaluate nursing facilities’ pain management programs.

Employ Other Modalities

A good pain management program relies on more than medication to manage pain, however. The Joint Commission on Accreditation of Healthcare Organizations’ pain standards also require  organizations to promote use of other modalities, says Marianna Kern Grachek, executive director of JCAHO’s longterm care and assisted living accreditation programs. Examples include use of therapeutic massage, diversion, relaxation and music.

Pain also has a strong psychological, social and spiritual dimension. Residents should be assessed for loneliness, which can aggravate physical pain or be a source of anguish in and of itself.

Some residents and families find comfort by exploring their pain and its personal meaning with clergy or spiritual counselors.

Re-Evaluate at Every Step

A successful pain management program also continually re-evaluates residents for pain and examines the effectiveness of the overall protocols at every step of the process.

“To provide optimal pain relief, facilities must differentiate between screening for pain and assessment and monitoring,” emphasizes David Gifford, chief medical officer for Rhode Island Quality Partners, a quality improvement organization working with facilities as part of the quality initiative.

“Screening questions are simple ones, such as: Are you in pain? Are you hurting or aching anywhere? If the resident says no, you don’t do the more comprehensive pain assessment that looks at the location, nature, intensity of pain and so forth,” Gifford tells Eli.

“Staff monitors the resident being treated for pain to see if he is having breakthrough pain or if the care plan needs to be changed.”