© Geriatric Times. All rights reserved.
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.