JCAHO Pain Standards
by Steven A. King, M.D., M.S.| Geriatric Times |  |
November/December 2000 | |
Vol. I | |
Issue 4 |
As any health care professional can attest, pain often can be difficult to manage. Yet, many patients suffer needless pain because they receive inadequate treatment. This may be a result of focusing on the primary medical problem while the pain is essentially ignored, or it may be because caregivers may not have the training to know the possible treatment options for pain.
The Joint Commission on Accreditation of Healthcare Organizations (JCAHO) has now officially recognized that pain is a major health problem and "patients have the right to appropriate assessment and management of pain" (JCAHO, 2000). The new requirements for pain management are included in the 2000-2001 standards manual for accreditation and will be scored for compliance in 2001. Although JCAHO offers some degree of leeway in instituting the guidelines, it spells out several specific requirements.
For example, pain assessment will be provided for all patients. According to the guidelines, pain will be the "fifth vital sign" to be recorded, along with temperature, pulse, respiration and blood pressure. The nature of the assessment tool is left to the determination of each health care system.
The standards suggest using the easiest tools to administer, such as asking the patient to score the pain on a 0 to 10 scale or on a simple descriptive scale ("no pain" to "worst possible pain"), and no doubt these types of scales will be used the most. The standards also remind physicians that noncommunicative patients, including geriatric patients with dementia or post-stroke patients, may require alternative methods of assessment, such as the children's scale that offers pictures of faces ranging from smiling to crying.
The standards highlight several other important issues involved in making an appropriate assessment of and treatment plan for pain management. The treatment example, "a unit caring for persons with Alzheimer's disease developed a pain scale for each resident based on long-standing knowledge of their residents and their knowledge of common pain syndromes in elderly patients," can certainly be extended to all noncommunicative geriatric patients.
Although these patients appear to suffer the same pain-associated disorders as those who can communicate, their pain is often less well managed (Sengstaken and King, 1993). Even when noncommunicative patients appear to be in distress from traumatic injuries that might result in significant pain, the pain may not be treated, simply because it cannot be reported.
The standards also emphasize the complex nature of pain and that it is much more than a simple physical phenomenon. This is notable in the statement, "Patients' psychosocial, spiritual, and cultural values affect how they respond to their care."
In order to improve that care, both patients and staff need to be educated about pain. Patients often receive little direct information about pain and, therefore, do not know what they can reasonably expect regarding its management. They may be given a general statement that their pain is a part of the underlying illness or secondary to procedures they have undergone. They are left to decide if the pain is at a level appropriate to the circumstances, with minimal guidance as to how to determine this. Patients need to have some idea as to when and how much pain can be reasonably expected, given their individual circumstances. They should also be made to feel comfortable about reporting pain without fear of being labeled "a complainer" or, even worse, "a drug seeker."
With regard to staff education, or rather the lack thereof, there is no doubt in my mind that this continues to be the major obstacle to proper pain management. Virtually every study that has examined the care of patients with pain has reported that many health care professionals do not know very much about pain management. As someone who has been actively involved for a number of years in trying to improve physician education on pain, I can attest to the sad fact that most physicians receive little or no training in pain during medical school or residencies, and what they do learn may be outdated. My sense is that most other health care professions provide a similar cursory education in pain.
The standards require that, at the least, hospitals hold twice-annual staff awareness events regarding pain assessment and treatment. In order to determine if the methods by which the standards are implemented are effective, "the appropriateness and effectiveness of pain management" are to be monitored by data collection.
Obviously, the fact that JCAHO allows a great deal of leeway in the implementation of standards provides both risks and benefits. Health care organizations and their staffs may choose to follow the minimal requirements. This will provide an improvement in care, but a significant amount of suffering may remain unaddressed.
In contrast, these basics may be viewed as a starting point that provides an opportunity to have a major impact on pain. If these standards are used, along with pain guidelines issued by organizations such as the Agency for Health Care Policy and Research (Jacox et al., 1994) and the American Pain Society (1999), care for patients with pain should significantly improve.
I strongly urge physicians and other health care providers who are interested in and concerned about the management of pain to find out how the hospitals and other facilities in which they practice plan to implement the JCAHO standards. This is especially important for those who frequently care for populations such as geriatric patients, who are especially prone to developing pain and may require special efforts to have their pain properly managed.
Dr. King is professor of psychiatry and director of the division of pain medicine at Temple University in Philadelphia.
References
American Pain Society (1999), Principles of Analgesic Use in the Treatment of Acute Pain and Cancer Pain. 4th ed. Glenview, Ill.: American Pain Society.
Jacox A, Carr DB, Payne R et al. (1994), Management of Cancer Pain. Clinical Practice Guideline No. 9. Rockville, Md.: Agency for Health Care Policy and Research.
Joint Commission on Accreditation of Healthcare Organizations (2000), Implementing the new pain management standards. Oakbrook Terrace, Ill.: JCAHO.
Sengstaken EA, King SA (1993), The problem of pain and its detection among geriatric nursing home residents. J Am Geriatr Soc 41(5):541-544.