The fifth vital sign: Transforming the way one home manages pain The staff at Columbia Lutheran Home knew they needed to make some changes. Quality measure comparisons, chart reviews, and the State's quarterly visits confirmed it—the existing systems just weren't good enough to successfully manage residents' pain. But how could the staff create such a significant transformation, and where would they start? Cathy Prentice, director of nursing, was looking for ways to revamp their systems when she came across two opportunities for outside assistance. "We were blessed," she said. "We were so fortunate to be selected for both the Swedish pain research study and the Qualis Health quality improvement project....It would have taken a lot longer without their help." For example, Columbia Lutheran Home was able to improve its chronic pain quality measure rapidly and dramatically: reducing the six-month rolling measure from 12.5% in October 2005 to 3.1% in May 2006. Being involved with these two initiatives gave the organization a push in the right direction, spurring the staff to work hard at analyzing the way they've handled pain in the past and making changes to effect a "complete culture change...now we look at pain as a quality of life issue," Prentice explained. "It's easy to take it for granted—if you're sick, you'll be in pain. But the thing is, being in pain is detrimental, emotionally and physically," she continued. "No one should have to suffer." Now the entire staff (including cafeteria, maintenance, and social service workers in addition to the medical personnel) is trained to spot the signs of pain. "One resource we found called pain 'the fifth vital sign' and that's been really helpful for us in changing the mindset. Pain needs constant assessment." Prentice said. To help the medical staff keep a close watch on assessing and monitoring pain, Prentice worked hard to create better tracking forms. "I wanted a super excellent tool. We probably revised the monitoring form 10 or 12 times," she admitted. Fortunately, all that effort has paid off. "Now the nurses really like the forms," Prentice noted. "It helps them feel better when they can see the results they are getting." The forms require staff to monitor the effectiveness of pain treatment—even for routine pain medication—and use a numeric scale to improve consistency in the rating assessment. (You may download copies of Columbia Lutheran Home's pain assessment and monitoring forms for your organization.) The nursing staff also has new confidence about providing pain-relief medications, thanks to some extra education. "With all the new drugs these days, just about everyone can have their pain controlled," Prentice remarked. "We simply needed more information about how and when to use the various types." (One educational tool your organization might consider is the Three-Step Analgesia Ladder.) Anticipating an ongoing need for information and evaluation, Columbia Lutheran Home formed a Pain Team which meets regularly to analyze performance. Prentice recommends that other organizations consider forming a similar group, but to keep it small. "There's a tendency to put everyone on a team, and then nothing gets done. Five or six people can get things going." To share across a broader group, pain topics are included in the organization's weekly interdisciplinary meetings. "If there is a patient having trouble with pain, everyone across the disciplines will know about it," Prentice stated. "Everyone is more on top of the situation now."

Download an argument in favor of depression screening for elders Patricia A. Parmelee, PhD., a noted longterm care researcher and professor at Emory University has some lively responses to the following objections regarding depression screening of nursing home residents. Objection 1: Using a validated depression screening tool is not necessary if the person does not appear depressed to the nursing home staff (social worker, nurse, physican). Objection 2: Formal depression screening is offensive and an assault on the dignity of the elder because it implies they might have a mental illness. Objection 3: An early screening completed in the first week after admission will only detect situational depression that will resolve without any other intervention as the elder adjusts to the new home.

Try these easy methods to combat pressure ulcers Is your facility making progress in decreasing the occurrence and severity of pressure ulcers? Try these simple techniques and you should see a difference. Take special care to screen new admissions for pressure ulcer risk Pressure ulcers tend to develop within the first few weeks of an admission. Identifying high-risk residents can go a long way in preventing the pressure ulcers from developing at all. Both the Braden Scale and the Norton Scale  have been tested for their effectiveness in quantifying pressure ulcer risk. An extensive Facility Assessment Checklist can also help you identify and resolve factors related to pressure ulcer risk. Simplify wound care product selection Eliminate "guess work" in treatment decisions by using one complete product line that includes items specific to each stage of care. Review the number of residents with pressure ulcers everyday Make good use of staff meetings and change-of-shift reports; reinforce pressure ulcer vigilence everyday.

Pain Management Tools
You may download copies of Columbia Lutheran Home's pain assessment and monitoring forms.

A variety of pain management tools are also stored on the MedQIC website.