Betsy Canino, assistant director of nursing at the Scandinavian Home in Cranston, can’t believe that this is the same patient.
A few months ago, the 89-year-old resident of the Cranston nursing home was cranky, withdrawn and refused to get out of bed. The staff thought she was depressed.
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Today, the woman willingly gets into her wheelchair and is able to go outside, get her hair done and go to church.
The difference? After asking a series of questions to better assess the woman’s pain, the nursing home staff discovered that a dislocated pin in her hip was causing her greater discomfort than anyone realized. It led to sleep deprivation, which left her irritable and depressed. Her pain medication was switched to a 24-hour patch, which proved far more effective than oral pills.
“What a difference it made in that lady’s life,” Canino said. “Now when I go into her room, she’ll kiss my hand and say ‘Thank you so much. I never thought I’d feel this good again.'”
The questions that revealed the source of the woman’s pain were part of a 15-month project to help 18 Rhode Island nursing homes improve pain assessment and pain management. The project was a joint venture between the Brown University Center for Gerontology & Health Care Research and Rhode Island Quality Partners (RIQP).
The program, completed last month, helped each facility implement standardized policies and procedures centered on either medication management – as in the case of the 89-year-old patient at Scandinavian Home – or non-drug interventions, such as massage therapy.
But perhaps more importantly, the nursing homes implemented protocols to monitor residents’ pain, primarily through the use of pain-intensity scales. For example, nurses at Scandinavian Home now ask the home’s 70 residents to rate their pain from 0 (no pain) to 5 (excruciating pain). Or, nurses can use a series of flashcards with faces used to depict the patient’s pain level: Choosing a face with a big smile means the patient has no pain at all, while picking a face twisted in agony reflects the highest level of pain.
Before participating in the program, Canino said Scandinavian Home’s approach to pain management was subjective.
“It depended a lot on the nurse’s background and training as to whether they asked the right questions or got the right information,” Canino said. “But with the pain-intensity scales, we’re able to quantify their pain in a consistent way.”
The idea is relatively straightforward: If you don’t ask a patient about his or her pain, you won’t be able to treat it effectively, according to Dr. Joan M. Teno, associate director of the Brown University Center for Gerontology & Health Care Research.
“If you’re trying to improve pain management, you have to have a routine way of assessing pain,” Teno said. The most common sources of pain for nursing home residents include osteoporosis, degenerative joint diseases, pressure ulcers, diabetes and cancer, she said.
Prior to the project, only 20 percent of the facilities regularly kept tabs on residents’ pain using pain-intensity scales. By the end of the program, nearly 80 percent of the homes had pain-assessment systems in place.
And the project also required the facilities to monitor the frequency of residents’ pain on an ongoing basis, making pain the “fifth vital sign” along with blood pressure, pulse, temperature and respiration. By doing that, the resident’s doctor can glance at the chart to see a history of the patient’s pain and adjust treatment accordingly.
Also, by the end of the project, more than 80 percent of the nursing homes were using non-drug treatments – remedies such as massage therapy, nerve stimulants and playing music – to manage the burden of patients’ pain, compared to fewer than half prior to the program’s implementation.
While quality improvement projects like the pain-assessment program can produce dramatic results, they’re not easy to implement, given the financial constraints and nursing shortages plaguing the industry.
“It’s hard to move the industry to unambiguously attend to (pain management) as aggressively as it might address other issues,” said Vincent Mor, chairman of Brown’s Department of Community Health. “It requires leadership, and that’s tough to find and sustain in an industry that by and large is not viewed very positively by the public.”
A national study published by Brown last spring – overseen by Teno – shows that 41 percent of all nursing home patients suffer from chronic, untreated pain. Rhode Island’s rate was about the same as the national average.
What makes the issue more important here, Teno said, is that nursing homes increasingly are the last place of residence for Rhode Islanders: One in three deaths in the state occurs in nursing homes – the sixth highest rate in the nation, according to Teno’s research. She attributes that to Rhode Island’s high percentage of elderly residents, which is the nation’s second highest.
Teno said there still is vast room for improvement in the realm of pain management. For example, nursing homes could do a better job choosing the correct type of medicine for patients, she said.
Moreover, only 18 of the state’s 100-plus nursing homes participated in the recent project.
But, for those that did, the program appears to have produced lasting results.
“We’ve had too much success to stop now,” Canino said. “It was a struggle to get the system in place, but now it’s like clockwork. Plus, it gives you a good feeling. We’re here to make people feel better.”
