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When Sea View Hospital Rehabilitation Center and Home, Staten Island, N.Y., chose to join the STAR (Setting Results Achieving Targets) initiative in 2003, staff and administrators didn't take the project lightly. By participating in this Island Peer Review Organization (IPRO) initiative, they hoped to make improvements in patient outcomes, especially unreported pain management, but they knew it would require everyone's hard work and commitment.

Four years later, the numbers speak volumes about the facility's success in pain management - chronic pain is down from 5.1% to 0.8% in residents. Because of its interdisciplinary efforts, the center has earned "recognition of achievement" for its quality improvement progress from the Nursing Home Quality Initiative (NHQI) in this and three other parameters: restraints, pressure ulcers, and depression. In addition, they've recently been awarded the IPRO quality award in recognition of quality care and service for pain management.

"Once a patient has triggered an assessment for pain, we begin an ongoing process of assessment to evaluate whether our pain management is effective or needs to be modified," says Carole Morgan, RN, BSN, MPA, LNHA, director of Nursing. Staff is constantly assessing for changes in pain patterns and breakthrough pain, and residents are reassessed at any point if an acute situation arises.

Matching the right tool

"We knew that if we could assess our residents' pain as accurately as possible, that would be half of our battle," says Marian McNamara, RN, MSN, associate director of Nursing. "After an extensive literature search, we developed a pain assessment tool that gives us a more accurate picture of our residents," Morgan adds. And they've managed to cover all bases - a complete pain assessment at admission, readmission, and at any time when a resident indicates verbally or nonverbally that he or she is experiencing pain. The assessment form is user-friendly for residents and staff.

For the verbal and nonverbal residents, staff designed a pain assessment tool that provides several options. Depending on their capabilities, residents can indicate the location of the pain on anatomical pictures; indicate the intensity on a scale from 1 to 10; describe the quality of the pain (i.e., throbbing, burning, radiating), and what factors, such as rest or movement, may relieve the pain. Residents who can verbalize are asked about the pattern of their pain, such as "Is the pain worse during movement, or at night?"

For those residents who are nonverbal, staff assesses residents for behaviors associated with pain, such as crying, calling out, screaming, moaning, or acting withdrawn or depressed. A space is provided for staff to describe "other" behaviors that are not listed. On readmission from the hospital, a reassessment tool was developed to prompt the nurse to look for pain symptoms and, if they are present, to complete a full pain assessment.

Matching the right interventions

Pain management at Sea View is more than pharmacological interventions. Based on the resident's assessment, the interdisciplinary team creates an action plan that might include exercise, relaxation techniques, massage, pet therapy, music therapy, hot or warm compresses, aromatherapy, and a hydration program. "We strive to individualize our interventions, and we prefer non-pharmaceutical ones," says McNamara.

"After the initial Minimum Data Set (MDS) assessment process, staff receives a QI report in which a resident may "trigger" for pain. Staff and administrators meet on weekly unit rounds, clinical update meetings, and monthly QI conferences to discuss effective interdisciplinary interventions that need to be initiated or modified to meet that resident's need for pain relief," says Maria McGuire, RNC, BSN, MPA, director of Care Management.

More than just numbers

Four years later, staff and administrators at Sea View are proud to say that according to IPRO, "There is a 52% relative improvement from quarter two of 2004 to quarter one of 2006."

But there's more to the story. Staff and administration have noticed that patients and families are more actively involved in their own care and eager to engage in facility-wide activities. Residents and families participated in an educational series that included topics on safety issues, medication management, and pain management. Because of the patient and family involvement in care, the pharmacist and the director of Nursing have discussed Sea View's pain management program at a resident council meeting.

In addition, IPRO has asked administrators to speak at roundtable discussions with staff from other LTC facilities and share their achievements at Sea View. The numbers support the facility's success in pain management, but its actions speak for the staff's commitment to pain management and to helping residents live their best quality of life.

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Janice Petrella Lynch, RN, MSN, is a managing editor for the New York/New Jersey division of Nursing Spectrum.

To comment, e-mail editorNY@nursingspectrum.com.

Editor's Note: To learn more about the pain assessment/management program at Sea View, contact mcguirem@seaviewsi.nychhc.org.

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