At the May 2018 skills fair, 21 of 44 eligible full-time, part-time, and per-diem nurses received training on the pain management algorithm. Of the nurses trained, 15 were full-time, one was part-time, and five were per-diem employees. Eligible nurses that did not attend the skills fair were assigned the content via Relias. Two nurses began, but did not complete the Relias training. The number of nurses who attended the May 2018 skills fair and received training during PDSA Cycle 1 were not tracked.
At the October 2018 skills fair, 23 of 45 eligible nurses received training on
modifications to the pain management algorithm and documentation of pain in the new EHR. Of the nurses trained, 18 were full-time, two were part-time, and three were per-diem employees. Eleven nurses received training at both the May 2018 and October 2018 skills fairs. In terms of turnover, in the interval between the skills fairs, four nurses left employment at CWRC, one of which had received training at the May 2018 skills fair. Five new nurses were hired during this interval, two of which received training at the October 2018 skills fair.
Prevalence of Potentially Painful Diagnoses
Data were collected on the number of residents who suffer from one or more potentially painful condition based on the list of diagnoses in their chart. There were at least 62 unique diagnoses, 39 of which were musculoskeletal in nature. Musculoskeletal diagnoses included: osteoarthritis, rheumatoid arthritis, fractures, rotator cuff injuries, degenerative disc disease, and herniated discs. Other diagnoses listed were due to: 1) neuropathic conditions (peripheral
neuropathy, herpes zoster and postherpetic neuralgia, fibromyalgia, trigeminal neuralgia), 2) gastrointestinal conditions (abdominal pain, epigastric pain, megacolon, hemorrhoids), 3) cardiac conditions (angina pectoris, chest pain, post-stroke pain syndrome), or 4) wounds (venous ulcer, pressure injury to hip). Other diagnoses were nonspecific in cause or location of pain (pain – unspecified, generalized pain, pain of unknown etiology). Counts were recorded of the number of residents with a potentially painful diagnosis per total number of residents audited in each care area. Table 1 presents the proportion of residents with documentation of a potentially painful diagnosis.
Table 1. Number of residents with a documented potentially painful diagnosis by care area Care Area Pre-Implementation Audit Post-Implementation Audit Building 4, 2nd floor 18/23 (78.2%) 24/24 (100%)
Building 4, 3rd floor 13/15 (86.7%) 17/18 (94.4%)
Building 6 10/10 (100%) 7/7 (100%)
Building 7 4/10 (40%) 9/9 (100%)
Rates of potentially painful diagnoses were higher during the post-implementation audit period in most care areas. Numbers of residents varied between the audits due to admissions or discharges from the facility. Residents’ charts were tracked by room number and admission date, allowing the DNP student to compare documentation on residents that were admitted to CWRC during both audit periods. Some residents did not have a potentially painful diagnosis documented in the pre-implementation audit, but did during the post-implementation audit. This may be attributable to the fact that new EHR requires documentation of an International
Classification of Diseases (ICD) diagnosis code for all medications at the time of order entry to justify prescription of the medication. This in turn may have increased documented rates of potentially painful diagnoses in during the post-implementation audit period.
Documentation
Documentation of pain by nurses was audited for 1) rates of documentation and 2) quality of documentation. Sixty-six residents’ charts were audited in the five-week pre-implementation period and 58 charts were audited in the six-week post-implementation review. Table 2 shows the number of charts reviewed by care area in the pre- and post-implementation audits.
Table 2. Number of charts reviewed
Care Area Pre Post
2nd floor 23 24
3rd floor 23 18
Building 6 10 7
Building 7 10 9
Rate of Documentation of Resident Pain
Rates of pain documentation in clinical progress notes were calculated using the number of charting opportunities for each resident. Each one-week interval that a resident was admitted during the audit period is one charting opportunity. If a resident was admitted to or discharged from CWRC during the audit period, their documentation was audited only for the duration of their stay. A charting opportunity was counted if a nurse documented any pain-related
information in a clinical progress note during each one-week interval of the audit. Table 3 shows the number of residents and potential charting opportunities observed during each audit period. Table 3. Number of charting opportunities by care area
2nd Floor 3rd Floor Building 6 Building 7
Pre Post Pre Post Pre Post Pre Post
# Residents 23 24 23 18 10 7 10 9
# Charting opportunities 101 140 68 103 45 42 50 54
The pre-implementation audit spanned a five-week period, while the post-implementation spanned a six-week period. The pain team felt that the first two weeks after the transition to the
new EHR were a period of upheaval. The post-implementation audit was extended by one week to allow comparisons between the first two weeks after transition and the following four weeks because it was expected that the change would begin to stabilize. Table 4 shows the rates of pain documentation in clinical progress notes during the pre- and post-implementation audits. Table 4. Rates of documentation of resident pain in clinical progress notes by number of charting opportunities
Care Area Pre Post: Week 1-2 Post: Week 3-6 Post: Total Building 4, 2nd Floor 33/101 (32.7%) 18/46 (39.1%) 23/94 (24.5%) 41/140 (29.3%) Building 4, 3rd Floor 21/68 (30.9%) 13/32 (40.6%) 19/71 (26.8%) 32/103 (31.1%) Building 6 14/45 (31.1%) 4/14 (28.6%) 10/28 (35.7%) 14/42 (33.3%) Building 7 6/50 (12.0%) 5/18 (27.8%) 8/36 (22.2%) 13/54 (24.1%)
Total documentation rates remained stable in three of four care areas after the transition, while one care area doubled their rates (Building 7: 12.0% to 24.1%). Three of four care areas (2nd floor, 3rd floor, Building 7) had higher documentation rates in the first two weeks after the transition than they did in the following four weeks. This is contrary to the expected outcome as documentation rates were expected to increase after the two-week transitional period.
Quality of Documentation of Resident Pain
The quality of pain-related documentation in nurses’ notes was assessed by counting the frequency of the presence of specific charting elements within the text of clinical progress notes. These elements were: documentation of a numerical pain score (0-10), the location of pain, the intervention given, and the effectiveness of the intervention. Table 5 shows the frequency of pain documentation elements in nurses’ clinical progress notes.
Table 5. Frequency of pain documentation elements
2nd Floor 3rd Floor Building 6 Building 7
Pre Post Pre Post Pre Post Pre Post
# Residents 23 24 23 18 10 7 10 9
Scale /10 2 10 10 7 9 1 2 0
Location 21 6 17 7 14 7 3 4
Intervention 18 8 26 13 11 10 2 4
Effectiveness 11 3 8 5 8 3 1 0
Documentation frequency increased for few elements post-implementation. A numerical pain score was documented more frequently on the 2nd floor and pain locations and interventions were documented more frequently in Building 7. In addition to fewer residents in three of four care areas during the post-implementation audit period, the decreased frequency of other elements in nurses’ clinical progress notes may be attributable to the addition of alternative places to document pain in the new EHR, which will be described next.
Use of EHR Tools
A feature was added to the MAR in the new EHR allowing nurses to document a
numerical pain score (0-10) and the pain assessment scale used (NRS or PAINAD) at the time of administration of pain medicine. Nurses were instructed on use of this feature during CWRC’s nurse end-user training. Information about this feature was not available at the time of the May skills fair, so it was not included in that training module. The post-implementation chart audit showed that nurses consistently charted a pain score and scale for as-needed pain medications, but did not for scheduled pain medications. Informal interviews of nurses during the October skills fair indicated that the MAR for scheduled medications appears differently from as-needed medications, with no place to document the pain scale and score.
The original EHR had a feature called “Med Effect” where nurses could document pain reassessments after medication administration, but did not prompt nurses to do so. The new EHR prompts nurses to document the resident’s response one hour after administration of as- needed pain medication. Reassessments may be numerical (0-10), chosen from a supplied list (“results – effective” or “results – ineffective”), or entered free text. Due to the high number of as-needed pain medications given during the audit period, adequate data were not collected in the chart audit to calculate the overall rate of responses documented on the MAR. However, the post-implementation audit revealed that this added MAR feature was effective in eliciting documentation of responses to medications. For example, one resident was given 37 as-needed doses of pain medication during the six-week audit period and had 37 medication responses documented. Nurses were most likely to document a response from the supplied list or enter free text. Examples of free text responses included: “Patient fast asleep after receiving oxycodone” and “Med effective – 7/10 now 3/10”.
A vital signs template was present in both the original and new EHRs to document temperature, blood pressure, heart rate, respirations, and pain. This template is most often used by nursing assistants at CWRC, who are responsible for measuring and documenting all vital signs except for pain. Nurses are responsible for assessment and documentation of pain. A numerical pain score was documented on the vital signs template 81 times in the five-week pre- implementation audit period, compared to 38 times in the six-week in post-implementation audit. It may be inferred that the use of the MAR to document pain assessments is contributory to the decreased frequency of use of the vital signs template.
An admission assessment template was built into the new EHR that includes an
assessment of current pain issues, and pain management strategies already in use. Of four residents admitted during the post-implementation audit period, none had pain assessments documented on the admission assessment template. Three of the four admissions were to Building 4, 3rd floor for short term rehabilitation and were, therefore, new to CWRC. It is unknown why admission assessments were not completed for these residents. The fourth admission was to Building 6 and the resident was already a member of the community. It is possible that nurses did complete do an admission assessment as this was an internal transfer of residence.
Skills Fair Feedback
The content of educational module presented at the October 2018 skills fair was based on findings of the post-implementation chart audit and modifications to the pain algorithm. After the educational presentation at the October skills fair, nurses were informally interviewed to elicit feedback about their experiences using the pain algorithm and documenting pain in the new EHR. Questions or comments about the content of the presentation were also encouraged in order to identify areas of concern or workflow issues that warranted further evaluation. Three main points emerged:
1. On the MAR, there is option to document a pain assessment (pain score, pain scale) for as-needed medications, but not for scheduled medications.
2. Content of clinical progress notes is guided by care plans applied to residents’ charts based on their list of diagnoses and active problems. Not all residents with chronic pain have care plans added to address this.
3. Some nonpharmacologic pain interventions require an order from a provider, while others do not. Nurses are not always certain which interventions they can apply without an order.
Current literature on EHR transitions and sustainability of change states that an audit and feedback process can improve nurse buy-in, performance, and satisfaction with change, as well as help to identify issues that may be addressed quickly to optimize per (Ivers et al., 2012; Rantz et al., 2011). For the purposes of this project, the DNP student presented these results back to the pain team as a way to formulate recommendations for immediate action steps and highlighting opportunities for future work, which will be further elaborated on in the next chapter.
Additionally, during the skills fairs and post-transition rounds to nursing units, nurses denied difficulties in following the pain algorithm and reported that they found the assessment tools to be helpful, particularly the PAINAD for assessment of residents with cognitive or
communication difficulties. However, this feedback could be biased as nurses may have been reluctant to report negative perceptions of the algorithm to the DNP student.