This morning, I was contacted by the emergency department. We had a patient who came in with severe agitated delirium to the point that no combination of sedative and anti-psychotic medications could...
One of our surgeons always has better pain management scores than anyone else. So, I asked our nurses why and they told me.
Every month, I review our hospital’s HCAHPS survey scores that measure patient satisfaction about their inpatient hospital stay. Two of the questions on the survey are about inpatient pain management:
- During this hospital stay, how often was your pain well controlled?
- During this hospital stay, how often did the hospital staff do everything they could to help you with your pain?
Pain control is particularly important in surgical patients. This particular surgeon does exclusively one type of surgery. She is very good at it but it is inherently one of the most painful surgical procedures that we do. It turns out that she uses the same pain medications that all of the other surgeons use, keeps her patients in the hospital for a normally expected amount of time, and uses the same physical therapists that work with all of the other surgeons. So, I was curious, why do her patients rate her so highly for pain management compared to everyone else?
The one thing that was different was setting expectations for her patients’ post-operative pain. In the office, before surgery, she tells them that they are going to have pain. In the pre-op holding area, she tells them that they are going to have pain and that pain medications will reduce but not eliminate their pain. In the post-op recovery area, she tells the patients and their families that they are going to have pain. When she gets ready to discharge them, she tells them that they are going to have pain when they get home.
She doesn’t try to scare the patients out of having their surgery but she she is honest about what they are going to feel. When pain is expected, it is much easier for patients to manage and when pain is unexpected, it is much harder to manage. I like to think of this as PAINting expectations for post-operative pain. The patients should expect that medications and therapy will keep their pain at about a 6/10 but prevent their pain from being a 9/10. Then, when their pain is actually a 6/10, then the patients feel that their pain was appropriately managed and their HCAHPS survey questions will be higher. If they were expecting it to be a 1/10 and it ends up bing a 6/10, then they will feel that their pain was not well-controlled.
It turns out that one of the best ways to improve pain management perceptions in surgical patients is to improve pain expectations for the post-operative period. This starts in the doctor’s office, continues in the recovery room, and continues on the hospital ward. It is something that the surgeon, the anesthesiologist, the office staff, the hospital nurses, and the physical therapists can all do. The solution is not to prescribe higher doses of opioid pain medications. The most important part of pain management is painting expectations for pain control.
November 20, 2017