VQC Acute Pain Management Measurement Audit Tool Guidelines

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1 Definition of Acute Pain The audit tools relate to acute pain only. Acute pain is defined as a normal physiologic and usually timelimited response to an adverse (noxious) chemical, thermal or mechanical stimulus, associated with surgery, trauma, and acute illness (McGraw-Hill Concise Dictionary of Modern Medicine, 2002). Introduction In 2007, the Victorian Quality Council (VQC) published the Acute Pain Management Measurement Toolkit ( the toolkit ). The toolkit aims to provide a range of validated measurement tools appropriate to the diverse needs of pain assessment. Following publication, the VQC implemented an intensive three-month project to support health services to implement the toolkit and evaluate its effectiveness. Feedback from the evaluation indicated that health services needed more guidance in relation to capturing acute pain management data and reviewing clinical performance at individual practitioner and organisational levels. In response to this request, the VQC has developed two audit tools to support health services to measure current practice in the management of acute pain. The organisational self assessment provides parameters for assessment of the structural support for effective pain management provided by the health service. The medical record review focuses on the clinical processes that support care at the bedside and can be used to measure the performance of individual clinicians and clinical teams. The purpose of the audit tools are to provide a simple mechanism to measure practice in these domains, and more importantly provide a robust mechanism for improving performance in this important clinical area. More specifically, the audit aims to improve clinical performance by: Promoting and maintaining minimum standards of care in acute pain management Ensuring organisational and clinician accountability for care Providing a standard against which organisations and clinicians can compare their performance to that of their peers Recognising organisation and individual clinicians for excellence in pain management Identifying professional opportunities for staff training in acute pain management Further explanation for each of the questions is provided below. 1 / 6

2 Organisation support and resources rces for pain management guidelines Question Interpretation and evidence 1-4 Variations exist in the terminology used for documents that support clinical practice. What is important is that requirements for pain management are formalised in organisational documents and that instructions for how to assess pain are available to clinical staff. Ideally an overarching organisational policy mandating minimum pain management requirements within your organisation is in place and supplemented by local procedures at specialised clinical levels. As a general rule, policy and protocols should be revised at a minimum of every 3 years. The policy, protocol or guidelines should include defined reportable observations which must be reported to medical officers or specialist Acute Pain Management Staff. Page 35 of the VQC toolkit outlines Reportable observations as follows: The patient has persistent severe pain, consecutive pain scores of 8-10/10 and/or 2 consecutive functional activity score (FAS) of C(severe limitation). The patient has a sedation scores of >/=2 The patient has a sedation score of >/=2 and respiratory rate < 8. The patient is experiencing any other side effects such as hypotension/bradycardia, nausea/vomiting, pruritus, urinary retention, back pain, high block, motor deficit, local anaesthetic toxicity, headache and norpethidine toxicity. 5 Compliance with protocols can be measured in a number of ways. This may include measuring the number of clinical events related to ineffective pain management. The Clinical Practice Audit provided as part of the Audit within this package, could include information in relation to compliance with your protocol. 6-9 Staff need to understand processes around pain assessment, documentation and reporting. Educational meetings and workshops have been shown to be effective in improving professional practice or health care outcomes A patient education brochure along with verbal explanation of the chosen subjective scoring system will enhance the patient s understanding of pain assessment and measurement. Ideally this should be given at preadmission or if patients are not pre-admitted, as early as possible in the admission. A sample brochure translated in 10 languages is available on the VQC website The toolkit provides examples of how pain assessment and reporting can be incorporated within the current observation chart format. This includes an area to record pain scores, functional activity scores and sedation scores along with other key physiological parameters collected by clinical staff to monitor the patient. 2 / 6

3 Governance of Pain Management Question Interpretation and evidence Performance Indicators can relate to structure, process and outcomes of healthcare. Structural indicators encompass issues such as the adequacy of facilities and equipment, the qualifications of clinical staff and administrative structures. Process indicators provide information regarding the impact of systems, policies and procedures. Where process indicators are evidence-based it is assumed that improved performance results in improved health outcomes as has been shown previously. 2,3 Outcome indicators refer to the patient s subsequent health status such as an improvement in symptoms. 4 The Australian Council on Healthcare Standards Clinical Indictor Program provides a range of Acute Pain Management Indicators within the Anaesthetic Indicator Suite Version 4. These include a mix of all types of indicators: Patient satisfaction with pain relief Analgesia adequate to enable acute rehabilitation Pain intensity scores recorded by nursing staff Occurrence of Defined Clinical Events Presence of an educational program for nursing staff Presence of formal protocols Occurrence of Major Adverse events - Persistent neurological dysfunction attributed to regional analgesia - Occurrence of an epidural haematoma / abscess following neuraxial technique The NSW Therapeutics Advisory Group (TAG) has developed two specific pain management process indicators that have been rigorously developed and tested. Please note however, that these are limited to post operative pain, and are therefore not applicable to medical patients. The indicators include: 4.1 Percentage of postoperative patients whose pain intensity is documented using an appropriate validated assessment tool 4.2 Percentage of postoperative patients that are given a written pain management plan at discharge and a copy is communicated to the primary care clinician Click on indicator for further information or go to the NSW TAG webpage: For Victorian public hospitals, the Victorian Patient Satisfaction Monitor (VPSM) includes a question: The help you received with your pain. The VPSM captures the satisfaction of approximately 40% of Victorian admitted patients, and may be a useful high level outcome indicator for pain management within your organisation. Hospitals who collect their own patient satisfaction data could consider adding a question on the patient s experience of pain management. It is generally accepted that collecting these data just prior to or immediately post discharge improves the reliability of data. 3 / 6

4 Governance of Pain Management (cont) Question Interpretation tion and evidence Complaint data may also provide an additional source of information for determining patients experience in relation to pain management. The number of incidents occurring in pain management as outlined in 2.3 may provide another outcome indicator, further information for which is detailed in 2.3. The Victorian Health Incident Management System, which is currently under development, classifies pain / discomfort as an unexpected outcome and includes a category for recording unsatisfactory pain control as an adverse event. This is expected to be in use across all Victorian public health services in Clinical practice audit guidelines Question Interpretation and evidence A range of validated tools for subjective and objective pain assessment are detailed within the toolkit. It is recommended that the type of assessment tool is recorded along with the results of the assessment As detailed in 1.0, the toolkit recommends that the treatment plan needs to be revised when deterioration in the patient is identified. Changes in treatment may include higher doses of analgesia or different medications and other interventions. 27 Distribution of brochures to the patient and/or the provision of verbal education should be documented within the medical record. 4 / 6

5 General Auditing Principles Leadership Senior clinical and management leadership for your audit program is crucial in ensuring that clinical staff see the audit program as important, that appropriate resources are made available and that improvement is possible. Keeping everyone informed of the process and maintaining an awareness of the overall aims will increase input from staff and encourage uptake of practice changes. Data collection ction and management As a variety of different people may be involved in data collection, ensuring consistency of data collection is vital and should be guided by a standard collection form. Clear data definitions and data collection rules are also important. Consideration should be given to training and/or support for those staff collecting the data as well as dedication of appropriate time for completing the audit. How many patient records do you need to review? The pragmatic guideline for selecting a sample size is that you need enough patients so that senior clinicians/managers will be willing to implement changes based on your findings. Sample size calculations depends on the size of the population you are looking at and the degree of accuracy required. Katz & Green (1997) 7 suggest guidelines on the amount of data to be collected depending on the purpose of the review: Type of Study Routine Review Query Review Intensive Review Sentinel Event Sample Size 5% of patient population in the review period or 30 (whichever is greater) 10% of patient population in the review period or 60 (whichever is greater) 15% of patient population in the review period or 90 (whichever is greater) 100% of patient population (every event) Once you have decided to take a sample and have decided on the size of that sample, the next question is which cases you are going to include in your audit. If you are looking at a small number of cases, or a narrow time period, you should take particular care to consider and eliminate potential sources of bias in your sample. Beware of daily, weekly or seasonal changes. For example, if you are conducting the audit during school holidays and many regular clinical staff are not at work, this may not be representative of care provided during non-holiday periods. Frequency of Audits The frequency of the clinical practice audit will depend on the resources you have available and other competing priorities on the improvement agenda within your organisation. As a general guide, 2-3 times a year would be ideal, until such time as a threshold level of performance is achieved. At that time, an annual audit may be sufficient to monitor practice. 5 / 6

6 The Staff Survey should ideally be completed annually. Benchmarking There may be an opportunity to benchmark performance against similar health services. For a complete list of those hospitals who participated in the Acute Pain Management Implementation Project, please refer to the final report available on the VQC website. References 1. Thomson O'Brien MA. Freemantle N, Oxman AD, Wolf F, Davis DA. Herrin J. (2005) Continuing education meetings and workshops: effects on professional practice and health care outcomes. Cochrane Database Systematic Reviews;1: CD Bradley EH, Herrin J, Elbel B, et al. Hospital quality for acute myocardial infarction: correlation among process measures and relationship with short-term mortality. The Journal of the American Medical Association 2006; 296: Peterson ED, Roe MT, Mulgund J, et al. Association between hospital process performance and outcomes among patients with acute coronary syndromes. The Journal of the American Medical Association 2006; 295: Australian Commission on Safety and Quality in Health Care. Measurement for Improvement Toolkit accessed on 13th October 2008 at BD2/$File/Toolkit_PartA.pdf 5. Thomson O'Brien MA. Oxman AD, Davis DA. Haynes RB, Freemantle N, Harvey EL. (2001) Audit and feedback: effects on professional practice and healthcare outcomes. Cochrane Database Systematic Reviews ;4:CD Thomson O'Brien MA, Oxman AD, Haynes RB, Davis DA. Freemantle N, Harvey EL. (2001) Local opinion leaders: effects on professional practice and health care outcomes. Cochrane Database Systematic Reviews ;4:CD Katz, J & Green, E (1997) MANAGING QUALITY A Guide to System-wide Performance Management in HealthCare. 2nd Edition, Mosby Year Book inc. St Louis, Missouri 6 / 6