Quality Improvement in Orthopedic Patient

¶ … Quality Improvement in Orthopedic Patient Pain Management

Because everyone experiences pain differently, formulating effective pain management protocols for patients in general and orthopedic patients in particular represents a challenging but timely and important enterprise. Despite the challenges involved, identifying opportunities to improve pain management has become the focus of accrediting agencies such as the Joint Commission on the Accreditation of Healthcare Organizations in recent years, but studies confirm that much remains to be done to achieve substantive improvements in this area. To gain some fresh insights concerning this ongoing initiative, this paper provides a summary of this initiative and the rationale in support of its selection, the relevance of this issue to healthcare practice and a review of the relevant literature to determine the importance of pain control in orthopedic patients and the adverse effects if pain is not well controlled. An analysis of the implications of these findings to healthcare practice is followed by salient recommendations and conclusions.

Organization

This issue was selected because the most common type of complaint in primary care settings is pain (McCaffrey, Frock and Garguilo 2003). In fact, absent significant levels of pain, many people simply go about their day-to-day lives without considering the need to visit a healthcare provider. In this regard, Hunter (2000) emphasizes that, "Pain is an experience that is common to most people, occurs in all areas of health care, and is the major reason for people to seek medical care" (p. 379). Despite being common, people experience pain in different ways, and the same people may even respond differently to the same pain stimuli at different times, making pain a nebulous phenomenon that defies easy evaluation (Eccleston, 2001). Currently, there are more than 76 million people in the United States suffer from pain, with orthopedic patients in particular tending to experience chronic or acute post-surgical pain (Facts about pain management, 2012).

On January 1, 2001, pain management standards went into effect for Joint Commission accredited ambulatory care facilities, behavioral health care organizations, critical access hospitals, home care providers, hospitals, office-based surgery practices, and long-term care providers. The pain management standards address the assessment and management of pain. The standards require organizations to:

1. Recognize the right of patients to appropriate assessment and management of pain;

2. Screen patients for pain during their initial assessment and, when clinically required, during ongoing, periodic re-assessments; and,

3. Educate patients suffering from pain and their families about pain management

Applicable pain management standards for orthopedic service require that patients be asked about their pain; however, some services within the tertiary healthcare organization may not been required to complete a pain assessment (such as an X-ray department) (Facts about pain management, 2012). Nevertheless, appropriate pain management should always be generally available if patients require it (Facts about pain management, 2012). The Joint Commission also reports that, "The organization's response to a patient's pain is based on the services it provides. If screening indicates that pain exists, the organization may assess and treat the pain; assess the pain and refer the patient for treatment; or refer the patient for further assessment" (Facts about pain management, 2012, para. 2). In addition, the Joint Commission encourages patients to report their pain and to cooperate with the treatment protocols prescribed (Facts about pain management, 2012). Taken together, current pain management standards demand an informed response from healthcare providers and these issues are discussed further below.

Relevance to Practice

By identifying best practices in orthopedic patient pain management, healthcare practitioners can help improve clinical outcomes and patient satisfaction levels in a cost-effective fashion.

Literature Review

According to Lukas (2004), approximately 11.5 million Americans (or about 50%) fail to receive adequate pain relief following surgical procedures each year using the most traditional pain management methods. The provision of adequate post-operative pain management, though, is complicated by profound differences in how pain is experienced by virtue of differences in cultural, psychological, biological and emotional factors (McCaffrey et al., 2003). By recognizing that pain is influenced by this constellation of factors at different times, it is possible for healthcare providers to provide improved pain management in their own clinical practice (Eccleston, 2011). While any surgical intervention will cause some degree of pain in most patients, the "Black-and-Decker" nature of much orthopedic surgery in particular can result in acute and chronic pain in many surgery patients. In this regard, Lukas emphasizes that, "Orthopedic patients experience high levels of pain that challenge traditional pain management techniques. Traditional pain modalities such as opioids can effectively reduce postoperative pain, but often with untoward side effects" (p. 8). A number of alternative treatment modalities have been used in an effort to avoid these adverse side effects, including various mind-body and therapeutical techniques that may prove efficacious in some orthopedic patients, but many healthcare providers remain unaware or untrained in their use (Lukas, 2004). For instance, one orthopedic nurse reports that, "In today's fast-paced surgical environment, perioperative nurses face many challenges to meet the needs of outpatients in helping to alleviate their pain and anxiety. Most nurses have not been taught non-pharmacologic methods for control of pain and anxiety" (Lukas, 2004 p. 8).

Besides this lack of training in providing adjunct treatment modalities for pain management in the orthopedic patient, there is also a pronounced lack of training concerning efficacious treatment modalities for younger orthopedic patients. For instance, Bennett-Branson and Craig (1999) emphasize that, "Despite advances in pharmacological approaches to pain control, most children who undergo surgery continue to experience moderate to severe postoperative pain. Children and their parents are forced to rely on personal resources to cope with this severe stressor" (p. 355). As noted above, individual manifestations of pain exist along a continuum that differs from time to time and place to place, but most adults are better able to communicate their level of post-operative pain to their healthcare team, while children under 5 years may be at a distinct disadvantage in this area. For orthopedic patients 5 years and over, though, McGrath (1996) reports that there are several self report measures of pain for children available, as well as observational measures such as facial action scales which appear to be most sensitive to children's post-operative pain. Despite the availability of these measures, many authorities suggest that children's parents should be actively involved in this formulation of pain management approaches, before, during and following surgical interventions. In this regard, Bennett-Branson and Craig (1999) add that parents are a reliable source of accurate information concerning the pain levels being experienced by their children, but that their children's anxiety level corresponded to the parents', suggesting that a family-oriented approach to pain management in the post-operative orthopedic pediatric patient is most appropriate (Bennett-Branson & Craig, 1999).

Implications for Practice