Nursing homes register 41 percent drop in residents' pain

December 03, 2004

PROVIDENCE, R.I. -- Relieving pain in nursing home residents doesn't require additional staff or a lot of money. What it takes: A multifaceted improvement process that stresses education, collaboration, mentoring and - most importantly - rapid changes in pain assessment and treatment.

Researchers at Brown Medical School and health care experts at Quality Partners of Rhode Island came to this conclusion after conducting an innovative study in 17 Rhode Island nursing homes. The team focused on a critical issue in elder care: how to treat pain.

Previous research has shown that four in 10 nursing home residents have persistent, severe pain. Yet several studies have found that complaints of pain often go unrecognized and that residents are inadequately treated - or not treated at all.

To address the problem, researchers at Brown Medical School teamed with Quality Partners of Rhode Island to test rapid-cycle quality improvement. Under that model, organizations set a clear performance goal, come up with tools to measure success, then make changes to hit their target. These changes are made - and their success measured - quickly. The "plan-do-study-act" process is ongoing, with refinements in practice made along the way. Researchers modified the model to include mentoring and information sharing.

Rapid-cycle quality improvement has been used to improve hospital care for nearly a decade. Last year, Brown Medical School researchers published results of the first test of the process in nursing homes in the nation, showing that it resulted in significant improvements in the prevention and treatment of bed sores. Now, the Brown and Quality Partners team is the first to apply the process to pain management.

The process produced some dramatic results in nursing homes in the study:

  • the use of appropriate pain assessments, which gauge factors such as intensity of discomfort and response to treatment, rose from 4 to 44 percent;
  • the use of pain intensity scales, which help caregivers monitor and treat pain, rose from 16 to 74 percent;
  • the use of non-drug pain treatments, such as heat packs, massage or better bed positioning, rose from 41 to 82 percent.

    Overall, researchers found a 41-percent reduction in pain among residents. Comparatively, all 95 nursing homes in Rhode Island only had a 12-percent reduction in pain during the study period.

    "We know we have to improve pain management, and we know what evidence-based strategies can get us there," said David Gifford, chief medical officer at Quality Partners and associate professor of medicine at Brown Medical School. "What we've shown is that when an organization puts these strategies in place, they get results."

    Twenty-one nursing homes took part in the study. Of those homes, 17 homes in 11 cities and towns completed the project. None received compensation.

    Participating homes pulled together teams of nurses, social workers, therapists, aides and other caregivers to lead improvement efforts during the 15-month project. A medical chart audit of the number of residents in pain was conducted at each nursing home. Homes received this data along with information on how they compared with other facilities in the study.

    Teams received six two-hour training sessions on effective pain management techniques. Each nursing home was assigned an experienced nurse to act as a mentor. Teams then chose strategies to test. These included more frequent pain assessments by nurses and more detailed medication requests for physicians. In one facility, nurses and aides wore "Ask me about your pain" buttons. Several homes tried to ease pain without drugs, using aromatherapy, massage, even individualized "comfort kits" for residents that included soothing music or family photos.

    Rosa Baier, project coordinator with Quality Partners and lead author of the study, said the dramatic reduction in pain under the project is the result of several factors, from the involvement of front-line caregivers to the singular focus on improvement.

    But Baier said duplicating the success could be challenging, given resource limitations in today's nursing homes. "Historically, nursing homes have been required to react to problems found in state inspections and this is a pro-active model that will involve a significant paradigm shift."

    Joan Teno, professor of community health and medicine at Brown Medical School and associate director of the University's Center for Gerontology and Health Care Research, said successful strategies taken from the study will be available on the Internet. With a two-year, $178,247 grant from the Mayday Fund, Brown and Quality Partners will create a Web site that provides nursing homes across the country with the education and tools needed to put rapid-cycle quality improvement plans in place. The site will debut in 2006.

    "These results show that nursing homes can improve pain management," Teno said. "The key is to not only educate health care providers, but to change what they do. Only then can you make meaningful improvement."

    The research team included Gail Patry, a project manager, and Sara Banks Freilich, a senior health information analyst, at Quality Partners. Therese Rochon, a nurse study coordinator, and Debra DeSilva, a former project coordinator, at Brown's Center for Gerontology and Health Care Research also worked on the project.
    The Robert Wood Johnson Foundation and the Centers for Medicare & Medicaid Services funded the work.

    Brown University

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