Improving Best Practice of Pain Documentation and Management: A Quality Improvement Initiative

From the 2019 HVPAA National Conference

Dr. Courtney McNamara (Children’s Hospital at Montefiore), Dr. Theresa Serra (Children’s Hospital at Montefiore), Ms. Alison DeSilva (Children’s Hospital at Montefiore), Ms. Sheila Buchanon (Children’s Hospital at Montefiore), Ms. Anne Marie Sterk (Children’s Hospital at Montefiore), Dr. Katherine O’Connor (Children’s Hospital at Montefiore)


Pain management is an essential component of patient care and satisfaction. JCAHO standards for pain assessment and management have been established and updated in 2018, yet implementation and improvement remain a challenge in many institutions. At our institution we observed documentation was inconsistent in using the appropriate developmental pain scale, timely treatment of moderate to severe pain and timely reassessment of pain. Our baseline data showed only 20% of postoperative patients on one unit had all 3 items appropriately documented. Our SMART AIM: By December 2018 to improve documentation of all 3 components of pain management in hospitalized postoperative pediatric patients on a single unit from 20% to 40%.


At our urban tertiary care hospital, a multidisciplinary QI team consisting of pediatric hospitalists, residents, nurse leaders, and child life specialists was formed.  Classic QI tools were used to plan targeted Plan-Do-Study-Act cycles. Interventions included: nursing education, placement of bedside pain scales, EMR tool as a reassessment reminder and house staff education. We collected baseline data for 8 weeks via a weekly review of 5 charts, and then study data for 12 months after starting interventions.  The primary outcome was correct documentation of pain scales, pain management and reassessment.  Our process measures were 1) Appropriate pain scale usage based on developmental age;  2) Medication administration within 30 min of a pain score >4 or a comment on alternative intervention; and 3) Reassessment within 60 min of medication administration for pain score >4. Run charts were utilized to graph the primary outcome and process measures. Nelson’s rules were used to determine special cause variation. Our balancing measure was average LOS of patients with uncomplicated appendicitis.


Following our intervention, appropriate overall documentation increased from baseline median of 20% to 40% (figure 1).  Documentation of the appropriate pain scale increased from baseline median of 55% to 80%.  The appropriate pain treatment remained at 80%. Reassessment improved from baseline median of 0% to 40%. The balancing measure of average LOS of uncomplicated appendicitis did not increase.


We achieved our goal of improving documentation of pain to 40%.  Reassessment of pain scores was the biggest barrier to improving our overall documentation rates above 40%.  More timely reassessment may be achieved in the future by better utilizing an EMR reminder tool and/or providing further nursing education.  We plan to spread our QI initiative to other inpatient units in the future.


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