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OASIS Alert

Training:

Correct Pain Discrepancies to Improve Accuracy and Patient Care

Published on Thu Jan 27, 2011

Do you know what qualifies as severe pain?

Assessing a patient's pain is just the first step in a comprehensive pain management program, experts say. Just as important is setting up a plan to mitigate the pain. You can use the OASIS assessment to help home in on patients who need help managing their pain.

Re-Think Your Severe Pain Approach

"Thirty-five percent of the OASIS assessments I review have problems with M1240 -- Has this patient had a formal Pain Assessment," says Kristi R. Wheeler, RN, HCS-D, COS-C, owner of ACCS (Agency Compliance & Consulting Service) in Terrell, Texas.

Bottom line: Your answer to M1240 may not contribute to case mix, but this item is important. M1240 is used to calculate process measures to capture your agency's use of best practices following the completion of the comprehensive assessment.

In addition to asking whether the patient has received a formal pain assessment, M1240 asks whether the assessment indicates severe pain. One inconsistency in answering this question is a discrepancy between documentation that shows a patient who is struggling with pain and an answer of 1 -- Yes, and it does not indicate severe pain for M1240, Wheeler says. Other times, there isn't enough documentation to support the M1240 answer 2 -- Yes, and it indicates severe pain.

For example: Documentation may show that a patient has been assessed for pain and scores 8, 9, or 10, but the clinician marks "1" for M1240. This could be a situation where the agency isn't setting a threshold for what is considered severe pain and requires intervention, Wheeler says.

Clinicians may also be fearful of answering "2" for M1240 for a couple of reasons, Wheeler says. Some may be concerned that answering "2" will mean they'll have to do more interventions, so they answer "1" instead, she says. Others may be afraid that the doctor will accuse them, or their patient, of drug seeking behavior.

Know Your Assessment Tool

There are several good tools commonly used in home care for pain assessment, says Pat Jump, with Rice Lake, Wis.-based Acorn's End Training & Consulting. Probably the most common tool is the zero-to-ten numeric pain intensity scale. This tool works well for most adult clients, Jump says.

The key to using this tool, however, is to make sure all clinicians know how to use it properly, Jump says. This includes knowing when pain is classified as "severe" according to the tool. "When doing OASIS training, I often ask clinicians which numeric values equate to severe pain and I get a variety of answers," she tells Eli.

Clinicians should also be familiar with the recommended language when administering the tool, Jump cautions. For example, don't use terms such as "the worst pain you have ever had" to describe a "10" on the intensity scale. Instead describe "10" as "the worst possible pain you can imagine."

Other pain intensity tools include the Wong-Baker Faces pain rating scale and the Pain Assessment in Advanced Dementia (PAINAD) scale, Jump says. The Wong-Baker tool is commonly used in pediatrics but can also be used for adults and sometimes works more effectively than the numeric scale to determine pain intensity when there is a language barrier or mild dementia.

The PAINAD, as the name implies, is most commonly used to determine pain intensity in persons with dementia, Jump says. This tool relies on observation of five behavioral indicators of pain. A trained clinician can use the scale in less than five minutes of observation, she says. Pain in the elderly is very often undertreated, especially in the elderly with dementia. This makes it even more important that clinicians complete a comprehensive pain assessment.

Create a Pain Management Plan

Once you have determined that your patient is experiencing severe pain, the next step is to create a pain management plan. You should do this in conjunction with the patient, the patient's family if appropriate, and the physician, Jump says.

For patients with chronic pain, determine what level of pain is acceptable if complete alleviation of pain is not feasible, Jump says. For example, a client who consistently rates his pain intensity as "8" may report he simply wants to get it to a "5."

Or a client may say she just wants the pain relieved enough that she can get up from the chair and walk to the bathroom fast enough so that she does not have any incontinence, Jump says. All reports of pain need to be addressed. Severe pain needs more aggressive interventions.

Interventions will vary considerably from one patient to another, Jump says. Explore interventions that work for each individual patient to set up an individualized care plan with client-specific goals, she says.

Important: Address not only pain reduction strategies but also interventions to deal with other pain consequences, such as lack of sleep, anxiety, and difficulty with mobility, Jump says. Sometimes the follow-up may be to involve therapy in the care of the patient. For example, physical therapy may be able to provide strengthening exercises or occupational therapy may instruct the patient on compensatory mechanisms.

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