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November 2000
Volume 64 |
Number 11
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| JCAHO's
Pain Initiative – New Opportunities/New Risks |
Hugh C. Gilbert,
M.D.
Carmen R. Green, M.D.
In
August 1999, the Joint Commission on Accreditation of Healthcare
Organizations (JCAHO) published its Pain Assessment and Management
Standards. This year, JCAHO surveyors are assessing compliance
of the pain management standards through interviews with families
and clinical staff and a facility's review of policies, procedures
and examination of a hospital or ambulatory facility's pain management
practice. In 2001, all accredited health care organizations will
be required to comply with the standards.
The pain management standards were developed
with input from the American Pain Society, consumer groups and
a variety of interested parties. To a large extent, the effort
to develop the standards was the product of a two-year collaborative
effort between JCAHO, the Robert Wood Johnson Foundation and the
University of Wisconsin-Madison Medical School.
Currently, JCAHO is sponsoring leadership
summits on pain management that are co-sponsored by Joint Commission
Resources, a JCAHO subsidiary, and the American Pain Society.
On May 22, JCAHO hosted its first leadership conference to highlight
the need for enhancing pain relief. At this leadership conference,
Perry G. Fine, M.D., Professor of Anesthesiology at the University
of Utah, led a panel discussion on the importance of educating
patients as well as practitioners about the importance of appropriate
assessment of pain. Leadership conferences emphasize the importance
of health care institutions developing programs to quantify the
impact of pain management strategies on the health and well-being
of patients. JCAHO believes that evidenced-based pain management
standards will have a dramatic positive impact on the estimated
120 million Americans who suffer from pain. Central to the pain
management standards is a new focus on pain assessment and management
as an essential element to all treatment plans. JCAHO's standards
require health care facilities to:
- Recognize the right of patients to
receive appropriate assessment and management of pain;
- Identify pain in patients during their
initial assessment;
- Document the efficacy of pain management
treatment plans;
- Educate patients and their families
about pain management.
The complete pain management standards
can be downloaded at: www.jcaho.org/standard/pm_ac.html#ri127
. JCAHO has sent a clear message that pain is now considered the
"fifth" vital sign and is to be assessed during all
patient encounters. Health care facilities are required to provide
educational materials and document that patients and their families
are informed of the intent to provide effective pain relief as
an integral aspect of their care. Patients should expect information
regarding appropriate options for enhanced pain relief and participate
in the decision regarding treatment of their symptoms. The pain
initiative is to be applied to all patient populations. JCAHO
stipulates that infants and children and impaired patients will
require special assessment tools based on developmental stage,
chronological age, function status and cognitive abilities.
A review of the ethics and patients' rights
section indicates that patients have the right to ask for pain
relief when pain first begins. Health care facilities are required
to have organized plans and support activities and resources,
ensuring that the pain of all patients is recognized and addressed.
Evidence of performance will be based on examination of policies
and procedures, chart audits, interviews with patients and families,
clinical staff and hospital leadership.
It is difficult to speculate how these
new pain standards will impact anesthesiologists, but clearly,
our specialty must embrace the spirit of JCAHO's new pain focus.
| "We are perceived as expert
operative pain busters by patients and their families. The
opportunity to develop clinical pathways addressing both pain
assessment and treatment has never been greater." |
New Opportunities
Pain management standards may be viewed
as an opportunity for anesthesiologists. We have a rich tradition
and significant literature devoted to the central issue of enhancing
pain control. We are perceived as expert operative "pain
busters" by patients and their families. Our literature underscores
the significant physiologic consequences associated with the undertreatment
of pain and documents the value of strategies unique to our expertise.
The opportunity to develop clinical pathways addressing both pain
assessment and treatment has never been greater. The opportunity
to initiate pain research by investigation and clinical trials
is highlighted in the standards as evidence for compliance. In
the best of circumstances, pain management standards enlarge the
focus of practicing anesthesiologists by enhancing our efforts
as perioperative physicians and pain management consultants.
New Risks
Pain management standards do not address
the issue of resources and utilization. In the worst case scenario,
anesthesiologists might find the demands for consultations and
management unrealistic and burdensome. Standards may well shift
the burden of pain management to anesthesiologists based on our
expertise and availability without regard to medical necessity
(appropriate need). The economic impact of JCAHO mandates has
never been well documented, and the transfer of responsibility
for pain management from one group of physicians to another may
have tremendous impact on the workforce and resource utilization.
Hospitals and clinics will need to devote resources to initiate
or enhance analgesic management programs.
Effective analgesia is difficult to achieve
in the entire hospital population. While developing interdisciplinary
strategies for assessment and treatment of pain should improve
comfort and outcome, emphasis on enhancing efficacy could result
in significant increases in side effects and/or complications
related to implementation of standardized analgesia protocols.
The variability of patients' responses to analgesics irrespective
of the methods of drug delivery implies that effective analgesia
is complicated and often associated with undesirable effects.
Meeting the expectation of patients, their families and other
health care professionals is often difficult.
Maximizing analgesic efficacy requires
a dedicated staff of health care professionals to continually
assess and modify analgesic protocols so that effective analgesia
can be delivered with minimal side effects. Developing strategies
to monitor positive and negative outcomes that must occur when
pain management is mandated extends beyond the scope of expertise
of many anesthesiology departments. Clearly, pain management standards
will require careful consideration by all concerned.
Since pain is a biopsychosocial phenomenon
of great complexity, the possibility for "missing the mark"
in a JCAHO audit is a significant risk. Hospitals that have acute
pain services up and running will be well served. The formulation
of pain management standards by JCAHO represents a good intention
that in many respects transcends the capability of current methods
of analgesia and drug delivery.
We need to know how often our unique methods
of analgesia meet the expectations of our patients, their families
and our health care colleagues. When dealing with JCAHO, "knowledge
is power."
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Hugh
C. Gilbert, M.D., is Associate Professor, Department of Anesthesiology,
Northwestern University, Evanston-Northwestern Health Care,
Evanston, IL |
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Carmen
R. Green, M.D., Department of Anesthesiology, University of
Michigan Medical Center, Ann Arbor, Michigan. |
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